The tragedy of multiple death nursing home fires, the need for a national commitment to safety

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Title:
The tragedy of multiple death nursing home fires, the need for a national commitment to safety report
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viii, 51 p. : ; 24 cm.
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English
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United States -- Congress. -- House. -- Select Committee on Aging. -- Subcommittee on Health and Long-Term Care
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Washington
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Subjects / Keywords:
Accidents -- Prevention   ( lcsh )
Fires and fire prevention -- United States   ( lcsh )
Nursing homes -- United States   ( lcsh )
Nursing homes -- Fires and fire prevention -- United States   ( lcsh )
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federal government publication   ( marcgt )
non-fiction   ( marcgt )

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Statement of Responsibility:
by the Subcommittee on Health and Long-Term Care of the Select Committee on Aging, House of Representatives, Ninety-fourth Congress, second session, September 1976.
General Note:
At head of title: Committee print.

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University of Florida
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All applicable rights reserved by the source institution and holding location.
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aleph - 025924228
oclc - 02560207
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nlm - WT 27 AA1 U44t 1976
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AA00025946:00001

Full Text
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[COMMITTEE PRINT]


THE TRAGEDY OF MULTIPLE DEATH NURSING
HOME FIRES: THE NEED FOR A NATIONAL
COMMITMENT TO SAFETY





REPORT

BY THE

SUBCOMMITTEE ON HEALTH AND
LONG-TERM CARE

OF THE

SELECT COMMITTEE ON AGING
HOUSE OF REPRESENTATIVES

NINETY-FOURTH CONGRESS
SECOND SESSION p f



$ l,,i,' ...' $4"
1978:4



SEPTEMBER 1976 4




Printed for the use of the Select Committee on Aging


77-4550'


U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 1976


For sale by the Superintendent of Documents. U.S. Government Printing Office
Washington, D.C. 20402 Price $.75 cents
There is 6 ietwm charge of $1.00 for each mail or4aer








SELECT COMMITTEE ON AGING
WM. 3. RANDALL, Missouri, Chairman


CLAUDE PEPPER, Florida
SPARK M. MATSUNAGA, Hawaii
EDWARD R. ROYBAL, California
FRED B. ROONEY, Pennsylvania
MARIO BIAGGI, New York
WALTER FLOWERS, Alabama
IKE F. ANDREWS, North Carolina
JOHN L. BURTON, California
EDWARD P. BEARD, Rhode Island
MICHAEL T. BLOUIN, Iowa
DON BONKER, Washington
THOMAS J. DOWNEY, New York
JAMES J. FLO RIO, New Jersey
HAROLD E. FORD, Tennessee
WILLIAM J. HUGHES, New Jersey
MARILYN LLOYD, Tennessee
JIM SANTINI, Nevada
TED RISENHOOVER, Oklahoma


BOB WILSON, California
WILLIAM C. WAMPLER, Virginia
JOHN PAUL HAMMERSCHMIDT, Arkansas
H. JOHN HEINZ III, Pennsylvania
WILLIAM S. COHEN, Maine
RONALD A. SARASIN, Connecticut
-VILLIAM F. WALSH, New York
CHARLES E. GRASSLEY, Iowa
GILBERT GUDE, Maryland


ROBERT M. HORNER, Staff Director
LYLE MCCLAIN, Counsel
ALBERT H. SOLOMON, JR., Professional Staff Assistant
MARTHA JANE MALONEY, Professional Staff Assistant
V. BERNICE KING, Financial Secretary


Subcommittee Membership
(WM. J. RANDALL, Missouri, Chairman of the full committee, and BOB WILSON, California, Ranking
Minority Member, are members of all subcommittees, ex officio.)
Subcommittee No. 1-Retirement Income and Employment
WM. J. RANDALL, Missouri, Chairman


WALTER FLOWERS, Alabama
JOHN L. BURTON, California
MICHAEL T. BLOUIN, Iowa
DON BONKER, Washington
THOMAS J. DOWNEY, New York


WILLIAM C. WAMPLER, Virginia
CHARLES E. GRASSLEY, Iowa
GILBERT GUDE, Maryland


MICHAEL W. MURRAY, Majority Staff
NANCY HOBBS, Minority Staff
Subcommittee No. 2-Health and Long-Term Care
CLAUDE PEPPER, Florida, Chairman


IKE F. ANDREWS, North Carolina
EDWARD P. BEARD, Rhode Island
JAMES J. FLORIO, New Jersey
MARILYN LLOYD, Tennessee


H. JOHN HEINZ III, Pennsylvania
WILLIAM S. COHEN, Maine


ROBERT S. WEINER, Majority Staff
ELLIOT STERN, Minority Staff
ALAN S. Zirp, Conultant

Subcommittee No. 3-Housing and Consumer Interests
EDWARD R. ROYBAL, California, Chairman


FRED B. ROONEY, Pennsylvania
HAROLD E. FORD, Tennessee
JIM SANTINI, Nevada


JOHN PAUL HAMMERSCHMIDT, Arkansas
WILLIAM F. WALSH, New York


JOSE S. GARZA, Majority Staff
PATRICIA C. LAWRENCE, Minority Staff
Subcommittee No. 4-Federal, State and Community Services
SPARK M. MATSUNAGA, Hawaii, Chairman


MARIO BIAGGI, New York
WILLIAM J. HUGHES, New Jersey
TED RISENHOOVER, Oklahoma


BOB WILSON, California
RONALD A. SARASIN, Connecticut


EDWARD F. HOWARD, Majority Staff
ROBETTA BRETSCH, Minority Staff
(11)












MEMORANDUM


To: Members of the Subcommittee on Health and Long-Term Care,
Select Committee on Aging.
From: Claude Pepper, Chairman.
Re: Nursing Home Fire Safety Report.
As part of its continuing examination of the health care problems of
the elderly, the Subcommittee on Health and Long-Term Care has in-
vestigated the fire safety problem of nursing homes. Multiple death
fires in nursing homes are a national tragedy which can and must
be eliminated. Elderly residents of nursing homes are entitled to a
safe environment.
This study is based on an intensive investigation by the Subcom-
mittee, including a joint hearing with the Senate Subcommittee on
Long-Term Care on June 3, 1976, on two recent tragic nursing home
fires in Chicago which killed 32 people and injured 50 others, as well
as similar fires elsewhere. In addition, a special investigation was
conducted by the U.S. General Accounting Office at my request.
Witnesses at the June 3 hearing included: Reverend William Pol-
lard, Chapel Reverend, Wincrest Nursing Home; Dr. Paul Hurwitz,
Examining Physician, Wincrest Nursing Home; Mr. Charles Chand-
ler, Administrator, Cermak House Nursing Home; Mr. James D.
Martin, Deputy Director, Manpower and Welfare Division, U.S. Gen-
eral Accounting Office; Mr. Robert E. Iffert, Assistant Director, Man-
power and Welfare Division, U.S. General Accounting Office; Mr.
Alan S. Zipp, Project Manager, Manpower and Welfare Division,
U.S. General Accounting Office; Dr. Faye G. Abdellah, Director,
Office of Long-Term Care, Department of Health, Education, and
Welfare; Mr. Marvin Hitt, Director, Office of Long-Term Care Stand-
ards Enforcement, Department of Health, Education, and Welfare;
Mr. Michael Morelli, Office of Long-Term Care, Department of Health,
Education, and Welfare; Mr. John Morehart, Office of Facilities,
Engineering, and Property Management, Department of Health, Edu-
cation, and Welfare; Mr. Gene Haislip, Deputy Assistant Secretary
for Legislation, Department of Health, Education, and Welfare; Mr.
George Hipps, Acting Director, Office of Underwriting Standards,
Department of Housing and Urban Development; Mr. Richard L.
Best, Fire Analysis Specialist, National Fire Protection Association;
Mr. Martin Grimes, Assistant Vice President, National Fire Protection
Association; and Mr. Ross Richardson, Assistant Illinois State Fire
Marshal. In addition, I wish to thank Mr. Francis Murphy, Chief of
the Chicago Fire Prevention Bureau, who gave valuable testimony at
the August 12, 1976, Chicago field hearing of the Subcommittee on
Retirement Income and Employment, chaired by our distinguished
(HI)







colleague, Win. J. Randall, Chairman of the full House Select Com-
mittee on Aging.
To all of these individuals, agencies, and groups, I wish -to extend my
thanks. In addition, I wish to commend and thank Mr. Alan S. Zipp
of the General Accounting Office for his very valuable assistance in
the preparation of this report, and I would like to thank the Honorable
Elmer B. Staats, U.S. Comptroller General, for allowing Mr. Zipp to
assist the subcommittee in this important area. I would also like to
thank the following people for their assistance: Mayor Richard Daley
of Chicago; Congresswoman Cardiss Collins of Chicago; Congress-
man Frank Annunzio of Chicago; Mr. J. Thomas Hughes, National
Fire Prevention and Control Administration; Mr. Irwin Benjamin,
National Bureau of Standards; and Ms. Janet Kline, Congressional
Research Service, Library of Congress.














CONTENTS

Page
Memorandum----------------------------------------------------- i
Summary of Findings and Recommendations------------------------- vII
Introduction----------------------------------------------------- 1
Background: Chicago Nursing Home Fires---------------------------- 3
Chapter 1--The Nature of Fire Protection----- ----------------------- 5
Institutional occupancies require special consideration -------------- 5
Evacuation of nursing home residents is just not practical- --------- 6
Code requires smoke detectors and automatic sprinklers in most cases- 7
How automatic sprinklers prevent death from smoke--------------- 7
Summary --------------------------------------------------- 8
Chapter 2-The Case for Automatic Sprinklers------------------------ 9
U.S. General Accounting Office---------------------------------- 9
Gage-Babcock & Associates, Inc., engineers/consultants------------ 9
Special investigation ordered by Chicago mayor------------------- 10
National Bureau of Standards of the U.S. Department of Commerce- 11
American Health Care Association: Full scale fire tests contracted by
HEW------------------------------------------------------ 11
U.S. Department of Health, Education, and Welfare------- -------- 12
National Fire Prevention and Control Administration-------------- 13
Senate Special Committee on Aging------------------------------ 13
House Committee on Government Operations--------------------- 14
American Health Care Association------------------------------- 15
National Safety Council---------------------------------------- 16
Roanoke County Fire Coordinator---- -------------------------- 16
Chief of the Chicago Fire Prevention Bureau---------------------- 16
Conclusion _-------------- -------------------------------- 17
Chapter 3-The Cost of Automatic Sprinklers------------------------- 19
How many nursing homes will be affected?----------------------- 19
Actual costs reported by the GAO----__------------------------ --20
What is a sprinkler system?------------------------------------ 20
Sprinkler cost per square foot ---------------------------------- 21
Cost projections on a square-foot basis--------------------------- 22
HEW and National Bureau of Standards cost estimates------------- 22
Subcommittee observation---------- ---------------------------- 23
Direct Federal loans are necessary------------------------------- 24
Medicare and medicaid reimbursement--------------------------- 25
Savings on unneeded construction modifications ------------------- 25
Possible savings on fire insurance ------------------------------- 27
New construction---------------------------------------------- 27
Arguments concerning the priority of the health dollar------------- 28
Chapter 4-Other Approaches to Fire Safety-------------------------- 29
The smoke detector alternative---------------------------------- 29
The automatic door closer alternative -- --------------------------30
Subcommittee observation-------------------------------------- 31
Chapter 5-Waivers from Fire Safety Requirements------------------- 33
Sprinkler requirement waivers ------------------------------- --33
Subcommittee observation-----__-------- -------------------- 34
Conclusions----------3--------- ------------------------------ 35
Recommendations------------------------------------------------ 36
Appendixes:
I: Related Reports on Fire Safety------------------------------- 37
II: Pending Congressional Legislation to Require Automatic
Sprinklers------------------------------------------------ 38
III: GAO Report Digest. "Federal Fire Safety Requirements Do
Not Insure Life Safety in Nursing Home Fires" ----------------- 49



















Digitized by the Internet Archive
in 2013














http://archive.org/details/tragedipl00unit












SUMMARY OF FINDINGS AND RECOMMENDATIONS-THE TRAGEDY OF
MULTIPLE DEATH NURSING HOME FIRES: THE NEED FOR A NATIONAL
COMMITMENT TO SAFETY
The Subcommittee on Health and Long-Term Care of the House
Select Committee on Aging has conducted an extensive investigation
of nursing home fire safety. Two nursing home fires, during early
1976, in Chicago, resulted in the deaths of 32 elderly residents and
injuries to 50 others. On June 3, 1976, a joint hearing on these and
other recent fires was held by the House and Senate Subcommittees
on Long-Term Care.
At the request of the House Subcommittee on Health and Long-
Term Care, the United -States General Accounting Office made an
independent investigation of the two Chicago fi res. The GAO report
was released at the June 3 hearing. The GAO found that both nurs-
ing facilities met all Federal fire safety requirements, but neither
home was protected with an automatic sprinkler system. The GAO
concluded that Federal fire safety requirements do not insure life
safety in nursing home fires. The GAO recommended that the Con-
gress enact legislation which will require that all nursing homes be
fully protected with automatic sprinkler systems.
The subcommittee found:
Nursing homes require special consideration because residents are
generally incapable of self-preservation due to age, and physical or
mental illness; and that neither adequate staff nor time is available
to evacuate all residents during a fire. The subcommittee found that
there has never been a multiple death fire in any nursing facility
fully protected with an automatic sprinkler system. Experts agree
that automatic sprinkler systems are the most effective known method
to prevent multiple death fires in nursing facilities. (See pp. 5-6.)
Another Chicago nursing home fire, within weeks of the two tragic
fires, was quickly extinguished, with no loss of life or injury, because
of an automatic sprinkler system. A professional engineering firm's
investigation of the Chicago fires concluded that "no single additional
protective measure except an automatic sprinkler system would have
definitely prevented this high loss of life." (See pp. 9-10.)
As a result of the Chicago fires, the City of Chicago enacted a City
Ordinance requiring all Chicago nursing facilities to install automatic
sprinkler systems. (See pp. 10-11.)
Experts agree that smoke detectors and heat detectors only give
notice that there is a fire, but take no action to extinguish the fire.
Sprinklers detect a fire, give an alarm and either extinguish or hold
a fire in check until outside aid arrives. (See p. 11.)
The National Bureau of Standards of the Department of Commerce
reported that its Center for Fire Research has concluded that "full
protection by automatic sprinklers in nursing homes is the best known
way to prevent disastrous multiple death fires." (See p. 11.)
(VII)






vmI


Test after test and report after report concludes that the single
most effective method of limiting the disastrous effects of fire is
through complete automatic sprinkler protection. (See pp. 9-17.)
The National Fire Prevention and Control Administration of the
Department of Commerce strongly advocates that all nursing homes
be provided with automatic sprinkler protection throughout. (See
p. 13.)
The cost of requiring all nursing homes to be fully protected with
automatic sprinkler systems is about 19t per bed (patient) per day
according to the General Accounting Office. The total national cost
has been estimated from $256 million to $412 million, including over
8,000 Medicare. and Medicaid nursing facilities (out of a total of
16,500) currently without sprinklers. This ranges from $32,000 to
$50,000 per nursing home for a permanent capital improvement. (See
pp. 20-23.)
Direct Federal loans to nursing facilities to pay for automatic sprin-
klers is the most expedient method to insure the availability of funds.
The loans should be repaid over 20 years with interest not to exceed
6 percent. (,See p. 24.)
Savings will occur in fire insurance premiums for a fully sprinklered
building and its contents. (See p. 27.)
All alternatives to full automatic sprinkler protection compromise
the necessary level of nursing home fire safety and are of questionable
cost effectiveness. While the subcommittee acknowledges that auto-
matic sprinklers have only limited effectiveness in preventing single
deaths of persons intimate with a fire, such as persons smoking in bed,
automatic sprinklers can almost totally, if not totally, eliminate multi-
pie death nursing home fires. (See pp. 29-31.)
The subcommittee recommends that the Congress enact legislation
requiring all nursing homes participating in Medicare or Medicaid to
be fully protected with an automatic sprinkler system and to provide
direct low interest loans to facilities for sprinkler installation. (See
p. 36.)












THE TRAGEDY OF MULTIPLE DEATH NURSING HOME
FIRES: THE NEED FOR A NATIONAL COMMITMENT TO
SAFETY

INTRODUCTION
Every year there are between 3,500 to 4,000 nursing home fires.
Throughout the years, thousands of our nation's elderly people have
been senselessly killed in nursing home fires, and thousands more have
been injured. An average of 50 people are killed annually in multiple
death nursing home fires, and over 500 are killed annually in fires in-
volving one or two people. Hundreds more are injured as a result of
these fires each year. Millions of dollars in damages are realized on a
recurring basis. In 1974, over $5.9 million was lost in direct property
loss from 9,300 nursing home fires.
On June 3, 1976, the House and Senate Subcommittees on Long-
Term Care held a joint hearing to investigate two nursing home fires
in which 32 people were killed and 50 injured. Both fires occurred in
the Chicago area early in 1976. The subcommittees heard testimony
from witnesses present at the fires; experts from the Chicago Fire De-
partment; representatives from the Departments of Health, Educa-
tion, and Welfare, and Housing and Urban Development; investi-
gators from the General Accounting Office; and fire protection
engineers from the National Fire Protection Association.
The conclusion of much research is that an automatic sprinkler sys-
tem is the most effective known method to prevent multiple death fires.
Many reports, both by congressional committees and others, have
recommended that, to save lives in cases of fire, all nursing homes
should be required to have automatic sprinkler systems.
It is argued that automatic sprinklers have only limited effectiveness
in preventing single death fires and consequently should not be re-
quired in all nursing facilities. The subcommittee recognizes that the
state-of-the-art in fire technology in protecting lives in single death
fires is limited, particularly where a person is in bed asleep when the
bed catches fire. While the subcommittee is very concerned with single
death fires, it firmly believes that the problem of multiple death fires
can and should be eliminated as soon as possible. The country has the
technology and the Congress has the authority to prevent multiple
death nursing home fires.
It is also argued that the cost of automatic sprinklers is too high to
justify such a requirement. The subcommittee believes the cost of
needless death and injury is too high to justify not requiring sprink-
lers. Three states, California, Massachusetts, Ohio, and the City of
Chicago, have enacted laws requiring all nursing homes under their
jurisdictions to be fully protected with automatic sprinkler systems.
The subcommittee asked the U.S. General Accounting Office to con-
duct a thorough, independent, and objective investigation of the two
(1)


77-455 0 76 2







Chicago nursing home fires and to make recommendations to prevent
this kind of tragedy from reoccurring. The GAO concluded that cur-
rent nursing home standards do not insure life safety in cases of fire.
It recommended that all nursing homes be fully protected with auto-
matic sprinkler systems.
Over the years, Congressional hearings have been held time and
again, to find out why so many people have been killed in nursing
home fires. In 1973 there were 6,400 nursing home fires, causing $3.6
million in property damages. In 1974, the National Fire Protection
Association reported there were 9,300 nursing home fires, causing over
$5.9 million in damages. These fires, during 1973, killed 51 people in
multiple death fires and about 500 in single death fires. During the
first two months of 1976, two nursing home fires resulted in the deaths
of 32 people.
Report after report has been published with findings that there is
a need for a system which acts automatically to prevent death in nurs-
ing home fires. The subcommittee agrees with this finding and strong-
ly recommends that the Congress enact legislation to require automa-
tic sprinklers in all federally funded nursing facilities. H.R. 14406 is
a bill, introduced by the subcommittee chairman, which is designed to
solve the problem of multiple deaths in nursing homes. A copy of this
bill is attached as an appendix to the subcommittee report.
The matter of multiple deaths from fire in nursing homes has been
discussed and investigated far too long. Action must be taken now.
Even while this report was being written, another nursing home fire,
in Roanoke, Va., killed four people and injured 28 others. The Con-
gress must take the initiative because the States have not acted. Auto-
matic sprinklers in all nursing homes can prevent multiple deaths
from fire from ever occurring again.
This report presents the results of the subcommittee's investigation
and draws upon evidence provided by many others in concluding that
there is a real need for automatic sprinkler systems. The subcommittee
hopes that action will be taken soon in this matter before more inno-
cent people are senselessly and needlessly killed by fire in nursing
homes.












BACKGROUND: CHICAGO NURSING HOME FIRES
Hundreds of pages of testimony have been received by various
congressional committees on the subject of nursing home fire safety.
In 1967, the Congress required that all nursing homes comply with
the Life Safety Code in an effort to insure a high level of fire safety
for nursing home residents. Subsequent to that action numerous fires
have occurred killing hundreds of innocent, helpless people, many in
nursing homes which do not comply with the Life Safety Code
requirements.
In early 1976, two nursing homes near Chicago had fires which re-
sulted in the deaths of 32 helpless elderly citizens. The Wincrest
Nursing Home is located in Chicago's north side. The four-story build-
ing was of fire resistive construction with a protected noncombustible
roof. The building had enclosed stairways. Heat detectors were pro-
vided in the chapel, stairways, and some closets, and one smoke detec-
tor in the corridor near the entrance to the chapel. Approximately 42
of the occupants of the building were in the chapel on the top floor
on January 30, 1976, when a fire in one of the patient's rooms on that
floor filled the corridor and chapel with heat and smoke. Reportedly,
a staff member of the nursing home had been charged with setting
the fire.
The fire started in the area of a wooden clothes wardrobe and ulti-
mately involved the contents of the entire room. Two wardrobes were
side by side constructed of plywood with hinged folding doors. Mat-
tresses were innerspring units consisting of 69 percent cotton felt and
31 percent sisal pad. These combustible contents contributed to fire
growth and development. In addition, the wallpaper on sleeping room
walls consisted of vinyl wall covering, which may have contributed
to the smoke production.
Fire damage was limited to the room of origin and the top portion
of a closet door across the corridor. The corridor opposite the room
of origin sustained heavy heat damage adjacent to and in both direc-
tions from the room of origin.
Thirty-five elderly residents were hospitalized as a result of the fire.
Thirteen patients died initially, but others had died after the fire, for
a total of 24 dead. No fatalities occurred in the room of fire origin,
which was unoccupied at the time of the fire. All residents who died-
with the possible exception of two-were located in the chapel.
The Cermak House is located in Cicero, Ill., immediately west of
Chicago. The Cermak House fire occurred on February 4, 1976, less
than one week following the Wincrest Nursing Home fire. This modern
nine-story intermediate care nursing home was of fire resistive construc-
tion with automatic closing smoke barrier doors in the corridors and
corridor smoke detection. On each floor, smoke barriers divided the
U-shaped building into a center section and an east and west wing.
The west wing housed six patient rooms with four patients per room.
(8)







A fire in a fourth floor room filled the west wing of that floor with
smoke and heat and caused the deaths of eight residents on that floor.
The fire started in the area of a combustible clothes wardrobe in
room 421 at about 6:30 a.m. At this time, the patients were being
awakened and were beginning their daily routine. The cause of the
fire had been attributed to a faulty electrical cord to the lamp on the
nightstand between the bed and the wardrobe. Combustible material
in the room contributing to the fire included mattresses containing 50
percent polyurethane foam plastic and chairs padded with urethane
foam plastic.
No fatalities occurred in the room of fire origin. The three occupants
of this room were removed by the nursing home staff. The fatalities
were from rooms in the wing of origin, except one from the center
section who apparently received exposure to smoke during evacuation.
Reportedly, this person was suffering from respiratory illness. The
corridor smoke doors worked as designed and contained most of the
heat and smoke in the wing of origin. Fire damage was limited to the
room of origin. Smoke and heat damage extended throughout the wing,
with smoke damage in those rooms with doors open. The carpeting in
the room of origin was consumed, but the carpeting in the corridor
did not burn.
Reports of the Cook County Coroner's Office had been reviewed
for 30 of the 32 victims of both fires, and they showed that the victims
died of smoke inhalation or smoke inhalation complicated by respira-
tory problems.
Thirteen of the Wincrest victims died on the day of the fire, and
all 13 deaths were attributed to smoke inhalation by the coroner's
physician. Most of the 11 other casualties died during the next two
weeks from smoke inhalation complicated by respiratory problems-
including pneumonia--or heart condition. The average age of these
victims was 80 years.
The coroner's report of the four Cermak victims who died on the day
of the fire showed the deaths as smoke inhalation. The other four
residents died later. In three cases, the cause of death was listed as
smoke inhalation. In the fourth case, the victim died of smoke inhala-
tion and extensive burns. The average age of the victims was 75 years.
The Wincrest and Cermak fires exhibited similar characteristics in
their place of origin, contents involvement, rapid growth and develop-
ment and smoke spread resulting in untenable conditions and tragic
results.
Both the Wincrest Nursing Home and the Cermak House fires
originated in a resident's sleeping room. The combustible contents of
the sleeping rooms at both fires contributed to the severity of the fires
and to the large quantities of toxic smoke produced.
Fire damage was essentially confined to the room of origin. The
construction of the walls, floors, and ceilings was adequate to confine
the fire to these rooms. The door openings between the rooms and cor-
ridors were the weak links, allowing the spread of smoke and toxic gas.
resulting in the tragic multiple fatalities. Neither home was protected
by an automatic sprinkler system.













CHAPTER 1


THE NATURE OF FIRE PROTECTION
Fire is the best of all servants; but what a master!-THOMAS
CARLYLE, Scotch Essayist.
The 1942 Cocoanut Grove Night Club fire in Boston, in which 492
lives were lost, focused national attention upon the importance of ade-
quate exits and related fire safety features. Public attention of exit
matters was further stimulated by a series of hotel fires in 1946 (La-
Salle, Chicago-61 dead; Canfield, Dubuque-19 dead; and the Wine-
coff, Atlanta-119 dead).
Under the Social Security Act, fire protection requirements for
nursing homes are directed by the 1967 and 1973 editions of the Na-
tional Fire Protection Association's Standard 101 Life Safety Code.
The Life Safety Code had its origin in the work of the Committee on
Safety to Life of the NFPA which was originally organized in 1913.
For the first few years of its existence the committee devoted its atten-
tion to a study of the notable fires involving loss of life and to an
analysis of the causes of this loss of life. This work led to the prepara-
tion of standards for the construction of various items such as stair-
ways and fire escapes, for fire drills in various occupancies, and for the
construction and arrangement of exit facilities for factories, schools,
and other buildings, which form the basis of the present Code.
The Life Safety Code has been mandated by Act of Congress as a
requirement for nursing homes participating in Medicare and
Medicaid.

INSTITUTIONAL OCCUPANCIES REQUIRE SPECIAL CONSIDERATION
Institutional buildings are those used for purposes such as medical
or other treatment or care of persons suffering from physical or mental
illness, disease or infirmity. Institutional buildings provide sleeping
facilities for the occupants and are mostly occupied by persons who
are incapable of self-preservation due to age, physical or mental dis-
ability, or security measures not under the occupants' control. Institu-
tional buildings include hospitals, nursing homes, and homes for the
aged.
According to the Life Safety Code, all institutional buildings shall
be so designed, constructed, maintained, and operated as to minimize
the possibility of a fire emergency which requires the evacuation of
occupants. The safety of occupants of institutional buildings cannot
be assured adequately by dependence on evacuation of the building, so
their protection from fire shall be provided by appropriate arrange-
(5)






6

ment of facilities, adequate staffing, and careful development of oper-
ating and maintenance procedures composed of the following: Proper
design, construction and compartmentation; provision for detection,
alarm, and extinguishment; and fire prevention, and the planning,
training, and drilling in programs for the isolation of fire and transfer
of occupants to areas of refuge or evacuation of the building.

EVACUATION OF NURSING HOME RESIDENTS Is JUST NOT PRACTICAL
According to Dr. Paul Hurwitz, a physician present at the Wincrest
fire, evacuation is simply not practical. At the June 3, 1976, subcom-
of occupants to areas of refuge or evacuation of the building.
I think it is well to point out that if we were to go right now, to any nursing
home, and drag 30 people down from the third floor it would kill a substantial
number. I think we have to remember, and remember throughout the day, that
evacuation is really futile. It is a waste of personnel because of the importance
of time. This 'thing took place in such a short number of minutes that we had to
limit our efforts to those which would save lives. Evacuation will not save lives.
The physician continued:
* * that to move a patient without hurting a senile, fragile body requires two
members of the staff over a couple of minutes. When you think of the chaos and
the pandemonium that reigned under the circumstances, you must remember you
are dealing with human elements and you have to remember that people are not
functioning quite on the level that they would in a drill.
As was pointed out in Senate Report 94-00, published in August
1975, by the Subcommittee on Long-Term Care of the Senate Special
Committee on Aging, many patients are under sedation or bound with
restraints. The report stated further that nursing home patients
present a particular problem because of several factors: (1) their
advanced age (average 82), (2) their failing health (average four
disabilities), (3) their mental disabilities (55 percent are mentally
impaired), (4) their reduced mobility (less than half can walk),
(5) their sensory impairment (loss of hearing, vision, or smell),
(6) their reduced tolerance to heat, smoke, and gases, and (7) their
greater susceptibility to shock.
Although the primary approach to nursing home fire safety has
been to confine the fire to permit adequate time to safely evacuate
the patients, it is apparent that there was neither adequate time nor
any assurance that evacuation would have prevented death at Win-
crest. As pointed out, from both fires, time is the most critical factor.
In both cases, only a short period of time passed from the identifica-
tion of the fires to the point that a lethal environment was created.
The subcommittee concludes that evacuation should not be the pri-
mary emphasis in protecting the lives of nursing home residents in
cases of fire. This approach cannot be relied upon because of the in-
adequate number of staff, the speed with which an effective evacuation
must be accomplished, and the poor physical conditions of the residents.
Evacuation should only be attempted when absolutely necessary.









CODE REQUIRES SMOKE DETECTORS AND AUTOMATIC SPRINKLERS IN
MOST CASES

The 1973 Life Safety Code requires that all new nursing homes be
fully equipped with an automatic smoke detection system. In addition,
the Code requires that all nursing homes be fully protected with an
automatic sprinkler system, except for those buildings of fire resistive
or one-story protected noncombustible construction.
During the subcommittee's June 3, 1976, hearing, Mr. Richard L.
Best, fire analysis specialist for the National Fire Protection Asso-
ciation, testified that:
* automatic sprinklers which will both detect and control incipient fires
as well as transmit the alarm signal to the fire department, must be considered.
The record of automatic sprinkler performance is good. The NFPA records do
not include any report of a multiple loss of life in a nursing home fully protected
by automatic sprinklers. Life safety will be considerably enhanced by the instal-
lation of automatic sprinkler protection in any nursing home regardless of
construction.
Mr. Best reported at the June 3 hearing the NFPA analysis of
the fires at the Wincrest and Cermak nursing homes:
The basic multiple death fire safety problem in health care facilities, as exem-
plified by these two fires, is the failure to confine a fire's resultant heat and smoke
to the room of origin. Fast-developing fires as occurred in the two Chicago area
nursing homes produced large quantities of smoke and other toxic gases that
escaped from the rooms of origin and caused occupant deaths within the area
directly exposed by the smoke and heat of the sleeping room fires-the third
floor and chapel at Wincrest and the west wing of the fourth floor at the Cermak
House. The combustibility of the sleeping room contents intensified the problem,
providing fuel for fast-developing and heavy toxic smoke producing fires. There
was insufficient time for nursing home staff to safely evacuate the occupants
from the area directly exposed by the smoke and heat of the sleeping room fires.
Time is of the essence. There is a need to slow the development of the fire or
at least confine its effects somehow; by reducing the amount of combustibles, by
closing the door to the room of origin, by eliminating or controlling the smoke
or by extinguishing the fire. These measures will buy the necessary time for
staff to evacuate occupants to an area of safety. The technology is available to
prevent multiple death fires from happening. Complete sprinkler protection in
all nursing homes regardless of construction in conjunction with other protective
features is one solution that would significantly reduce the risk of multiple life
loss.

How AUTOMATIC SPRINKLERS PREVENT DEATH FROM SMOKE

According to experts from the National Fire Protection Association:
Sprinklers have an excellent record of extinguishing fires. Although there can
be smoke generated in the incipient stage of a fire, and additional smoke
developed even though the fire is controlled by the sprinklers, the sprinklers will
reduce the amount of smoke produced in a fire. As in Wincrest, had there been
sprinkler protection in the room, even if the fire had not been completely extin-
guished at the wardrobe, it would have prevented the burning of the rest of the
contents in the room. It would have reduced the overall amount of smoke.
Sprinklers will react when the critical temperature occurs, but that allows a
sufficient time for a fire to begin to develop before it operates. The sprinkler








then operates over the fire and it may completely extinguish the fire. But if it is
something like a mattress or chair, it might continue to smoke, but it will not
spread. Some smoke will go through the building, however, it will be cool smoke
because it had to pass through a spray of water. It will not have pressure or
the ability to travel very far and probably would not have a lethal effect. It
might irritate, but it would not have so much lethal gas.

SUxXARY
Nursing home residents cannot be expected to evacuate themselves
in cases of fire. The speed with which a fire can develop and cause
death prevents evacuation from being considered as a first line of
defense in a nursing home fire situation. The most reliable and effec-
tive method of insuring life safety is early detection and prompt ex-
tinguishment of the fire through automatic means without the need for
human reaction or judgment. The subcommittee believes that auto-
matic sprinkler systems which can detect and extinguish fires are the
most effective method of preventing multiple death fires in nursing
homes.














CHAPTER 2


THE CASE FOR AUTOMATIC SPRINKLERS

U.S. GENERAL ACCOUNTING OFFICE

At the House-Senate joint subcommittees' hearing of June 3, 1976,
the United States General Accounting Office released the results of
an investigation requested by Chairman Pepper, of the Wincrest,
Cermak, and other recent nursing home fires. The General Account-
ing Office report entitled "Federal Fire Safety Requirements Do Not
Insure Life Safety in Nursing Home Fires," recommended that "the
Congress enact legislation which will require that all nursing facilities
be fully protected with an automatic sprinkler system."
The Comptroller General's General Accounting Office report cited
a nursing home fire case, occurring within weeks of the Wincrest and
Cermak House fires which resulted in no injuries, deaths, and little
damage because of an automatic sprinkler system. The GAO report
stated:
* the Plaza Nursing Home fire occurred on February 18, 1976. The Plaza
Nursing Home, a skilled nursing facility in Niles, Illinois, can accommodate 300
residents. At the time of the fire, 224 residents; including both Medicare and
Medicaid patients, occupied the home.
A nurses' aide noted smoke and a burning mattress in room 421 (no one was
in the bed) and, with a nurse's assistance, evacuated the three occupants of the
room. The nurse activated a pull-box alarm and closed the room door. The fire
activated one of two sprinklers in the room which sprayed water on the fire.
The sprinkler extinguished the fire before the firemen arrived, which was shortly
after the alarm.
The fire did not cause any deaths or injuries to residents at the Plaza Nursing
Home. Fire damage was confined to the mattress and little, if any, heat or smoke
damage occurred.
The Fire Chief attributed the absence of injuries and the prompt control of the
fire to the sprinkler system and the quick employee response. Because the fire
was promptly controlled, it did not generate sufficient heat (160 degrees Fahren-
heit) to activate the second sprinkler in the room.
An official of the Illinois Fire Marshal's office attributed the cause of the fire
to the careless use of smoking materials by a resident.

GAGE-BABCOCK & ASSOCIATES, INC., ENGINEERS/CONSULTANTS

At the request of the American Health Care Association (formerly
the American Nursing Home Association), Gage-Babcock & Associ-
'ates, Inc., was asked to investigate the Wincrest and Cermak House
fires.
The engineering firm's report on the Wincrest fire concludes that:
* no single additional protective measure except an automatic sprinkler
system would have definitely prevented this high loss of life. Other protective
measures would have still depended on specific staff and fire department reactions.
Early warning smoke detectors would not have provided any significant benefit
since there was no evidence that delayed alarm transmission contributed to
the loss. Fire tests have shown that a wooden wardrobe fire can develop very
(9)


77-455 0- 76 3







10

rapidly and involve an entire room within a few minutes. Automatic door
closer would have quickly dampened the fire and provided time to evacuate
occupants if the door to the fire room was kept closed. This would have required
both the staff and the fire department to refrain from extinguishing the fire
until all occupants were removed to a place of safety.
Doors on the chapel, which are required under the 1973 Life Safety Code,
would have impeded smoke entrance. The chapel would have remained tenable
if these doors remained closed and some chapel windows were opened. However,
if either the staff, or the fire department attempted to "rescue" the occupants
of the chapel it would negate the benefit of the doors. In addition, "rescue"
efforts would have required moving the patients toward the fire area. A second
exit stairway from the chapel would have been of little benefit since most patients
could not have used it. It would have probably reduced the loss of life some-
what since rescue would have been easier.
The engineering firm's report on the Cermak House fire concluded
that:
* the fire resistive construction did not contain the fire any better than
protected wood frame construction would have. An automatic sprinkler system
would have promptly suppressed this fire. Patient room door closer would have
contained the fire and since all patients would have been in rooms behind closed
doors, the life loss might have been prevented. This would have required that
neither the staff nor the fire department would have evacuated patients until
the fire was suppressed and the floor ventilated. In addition, the patient rooms
near the fire room would have had to be ventilated to prevent buildup of smoke,
which would come through the walls. There was time for all of this to have been
done by the staff instead of attempting evacuation. However, the universal tend-
ency and training is, and probably will remain, to evacuate all occupants at least
on the fire floor. As long as codes and training emphasize fire fighting and having
ample fire extinguishers available, the staff will continue to attempt to extinguish
fires rather than closing a fire room door.

SPECIAL INVESTIGATION ORDERED BY CHICAGO MAYOR

Mayor Richard J. Daley appointed a special panel to investigate
and record all facts related to the fire and subsequent deaths which
occurred at the Wincrest Nursing Home on January 30, 1976, and to
draw such conclusions as are supported by the facts and to make
recommendations to prevent a similar tragedy from recurring. The
investigation concluded that:
No matter what the cause of ignition, this fire demonstrates that a modern,
well-built, well-maintained nursing home that complies with present regulations
is still vulnerable to a disaster of this magnitude.
There was no evidence of panic. The problem lay with the inability of the
elderly residents to evacuate themselves from the fire floor, and the difficulty
of moving wheel-chair patients down the available stairs.
Occupancies of this type must be capable of protecting the residents during the
course of a fire without relying on evacuation.
Limiting combustible items, furniture and bedding would not entirely solve the
problem and would be in part dehumanizing.
Providing self-closers on corridor doors held in the open position with magnetic
hold open devices activated by smoke detectors would be an inadequate form of
protection for institutional sleeping rooms. These devices are too subject to
various types of failure and could prove dangerous to older people who may
accidently bump such a door, releasing the self closer. Facing the practical
operational realities, wedges and furniture would very likely be placed to negate
the effectiveness of the door closer. In addition, self closing devices activated
by smoke may trap a number of residents in the fire room making it difficult
for them to exit themselves or with attendants' assistance. Also, these devices
are by no means an inexpensive solution in both their initial and maintenance
cost.
Smoke detectors or heat detectors only notify that there is a fire. Many of
the people in nursing homes cannot take proper action, themselves, but must









then rely on attendants. There are not normally enough attendants to move all
threatened residents to a safe enough location to endure the fire, smoke, and
gases that may develop in an uncontrolled fire before the arrival of the fire
department.
Smoke barriers in corridors protect the occupants on the non-fire side but
are not a solution for those on the fire side.
The proper emergency action of attendants is important but again is not a
complete solution. Their decision to fight a fire or use that time to remove
residents from a dangerous area must be made in split seconds. Should the
fire proceed beyond their control, they must have enough time and training
to remove all affected people to a safe area. Quite often that time is not available
or the training is inadequate.
Sprinklers detect a fire, give an alarm and either extinguish or hold a fire in
check until outside aid arrives. They also control, indirectly, the amount of
smoke generated. They would limit a fire to a size that would be controlled by
attendants and would also provide the time necessary to remove residents to a
safe area. They will not, however, prevent fire nor will they prevent a person in
the immediate vicinity of a fire from being affected by that fire. They will, how-
ever, protect other residents by controlling the fire and thereby the smoke, gas,
and heat, and will also give attendants the time necessary to affect the immedi-
ate relocation of threatened individuals.
The recommendations of the investigation panel included that:
* the following requirements should immediately be made part of the
Building and Fire Ordinances of the City:
Sprinkler systems to be installed in all new and existing nursing homes and
be electrically interconnected with the fire alarm system.
On April 7, 1976, this recommendation was approved by the City
Council. It requires all Chicago nursing homes to install sprinkler
systems by February 1, 1977.

NATIONAL BUREAU OF STANDARDS OF THE U.S. DEPARTMENT
OF COMMERCE

In commenting on the General Accounting Office report recom-
mending that all nursing homes be required to install 'automatic
sprinkler systems, the National Bureau of Standards made the follow-
ing statements regarding multiple death nursing home fire safety:
The Center for Fire Research has reviewed the report and other available
information. We make the following comments: "Full protection by automatic
sprinklers in nursing homes is the best known way to prevent disastrous multiple
death fires. The Center concludes that the recommendation for full sprinkler
protection in nursing homes will, if fully implemented, prevent most and perhaps
all multiple death fires; however, the effectiveness of an automatic sprinkler
system in preventing or minimizing the individual fire death problem in health
care facilities is limited."
The Bureau of Standards also proposed alternatives to full auto-
matic sprinkler protection which are presented in Chapter 4.

AMERICAN HEALTH CARE ASSOCIATION: FULL SCALE
FIRE TESTS CONTRACTED BY HEW

During the summer of 1974, the American Health Care Association
(formerly the American Nursing Home Association), under contract
to HEW, made a series of 14 monitored fire tests, some of which were
carried out in 'an abandoned nursing home near Gary, Ind. The tests
were conducted by Gage-Babcock & Associates, Inc., a fire safety
engineering firm, with technical assistance of the Illinois Institute







12


of Technology Research Institute. This program was conducted for
the Bureau of Quality Assurance, Department of Health, Education,
and Welfare, by the American Health Care Association under contract.
Five of these tests were conducted in a fire test laboratory which
was representative of a nursing home of fire resistive construction.
Three tests were conducted in a vacated wood frame nursing home,
and six in a modified apartment of brick-wood joist construction.
According to the American Health Care Association's report of the.
test results:
The primary conclusions of this program were that current fire safety con-
struction standards and corridor wall construction having a one-hour fire resist-
ance rating provide no significant life safety function in buildings protected
by automatic sprinklers.
* S
Automatic sprinklers readily controlled rapidly developing fires in patient
rooms which were finished with Class C flamespread index prefinished plywood
wall paneling and wood-fiber ceiling tiles (tests 9, 11, 12). In all of these tests
the fire was largely shielded from direct contact with the sprinkler discharge.
In addition, the room in tests 11 and 12 was cross-ventilated by opening two
windows prior to starting the fire to reduce the accumulation of water vapor
which might indirectly extinguish the fire. No lethal levels of temperatures (at
the 5 ft. level) or carbon monoxide were recorded in these tests either inside or
outside the burn room.
In tests 7 and 14, which were conducted to determine fire development without
sprinkler protection, sprinklers in the fire room were manually actuated to
terminate the test. Sprinkler operation quickly suppressed both well developed
fires.
4 S *
The conclusions of this program are directed to protection against the rapidly
developing fire which poses a multiple life loss threat in an existing nursing
home. The smoldering fire which generally poses a threat to a single life was not
within the scope of the program.
The principal conclusion of the program was that ordinary noncombustible
interior finishes commonly found in existing wood-frame and brick, wood-joist
buildings provides adequate fire protection for the combustible structure in
sprinklered buildings. * *
With automatic sprinklers, the fire does not last long enough for its behavior
to be affected even by Class C combustible wall paneling and ceiling tiles. * *

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

At the joint House-Senate Subcommittees' bearing of June 3, 1976,
Dr. Faye G. Abdellah, Director of the HEW Office of Long-Term
Care and Special Assistant to the HEW Undersecretary for Long-
Term Care, presented testimony regarding the HEW view of sprinkler
systems in nursing homes. The following excerpts indicate the De-
partment's position:
A very important point we would like to make is that the standards today
provide only an acceptable degree of safety, not the maximum degree of safety.
*
The 1973 edition of the Life Safety Code does not require automatic sprinklers
in buildings of fire resistive construction, regardless of height, as does the 1967
Code, and buildings up to three stories in height if they are of protected, non-
combustible construction. There are other variations regarding construction
types and sprinkler requirements in the 1973 Code.
The recent tragic fires in Illinois have raised serious questions as to the degree
The recent tragic fires in Illinois have raised serious questions as -to the degree







13

of safety provided in institutions of fire resistive construction that are not re-
quired to have automatic sprinklers. These facilities were in compliance with the
provisions of the Life Safety Code, yet 32 elderly residents perished. We in HEW
are deeply concerned over these tragedies.
Over the past several years, there has been an increasing body of opinion
which argues for requiring automatic sprinkler protection in all nursing homes
without regard to type of construction. A few States such as California and Ohio
and most recently the City of Chicago, require that all nursing homes have
automatic sprinkler protection.
*
The Department has a contract with the National Bureau of Standards to
study the effectiveness of many of the fire safety requirements pertaining to
institutional occupancies and to determine whether additional or different re-
quirements should be mandated. One of the things they are looking at is the
placing of automatic sprinklers at selected locations rather than throughout
a facility; there is no question that there is evidence to show that lives can be
saved by automatic sprinklers.
S *
Automatic sprinklers do help prevent multiple death fires. The NFPA has
never reported multiple death fires in buildings which were completely
sprinklered.

NATIONAL FmE PREVENTION AND CONTROL ADMINISTRATION

The National Fire Prevention and Control Administration of the
U.S. Department of Commerce, commented on the recommendation to
the Congress that all nursing homes be required to have automatic
sprinkler protection.
We strongly advocate that rll nursing homes should be provided with automatic
sprinkler systems throughout in accordance with the national consensus standard
for sprinkler systems of the National Fire Protection Association (NFPA No. 13).
We also urge that "trade offs" in building construction and equipment be en-
couraged when automatic sprinklers are provided as specified in the Life Safety
Code also produced by the National Fire Protection Association (NFPA No. 101).

SENATE SPECIAL COMMITTEE ON AGING

In August 1975, the Subcommittee on Long-Term Care of the Senate
Special Committee on Aging published a report "The Continuing
Chronicle of Nursing Home Fires." The report pointed out that:
* few issues have stirred so much legislative and regulatory concern as
fatal fires in nursing homes. On the Federal level, multideath tragedies of this
kind have instigated investigations, hearings, and legislation intended to spur
corrective action. In 1967, 1971, and 1972 significant action was taken by the
Congress to raise safety standards to new and more satisfactory levels. But this
supporting paper must report that serious gaps still exist in overall protection.
As is evident from prior fire experience, neither the patient nor the nursing
home staff are capable of taking action to prevent loss of life in a major nursing
home fire. Automatic detection systems are helpful, but the best fire safety
approach incorporates automatic extinguishment as well as automatic detection.
As Profesor Irving Einhorn of the University of Utah has stated: "No single
system is foolproof but, by and large, sprinklers are the difference between life
and death. They are'the difference between heavy and light property loss as well."
By and large, most experts agree that in the nursing home context, the best
technological solution to fire safety is a fully automatic sprinkler system.
After the NFPA staff investigation of the Marietta fire, Mr. Richard Stevens,
Assistant Vice President for Standards of the National Fire Protection Asso-
ciation testified that: "I think the sprinkler would have stopped all production
of smoke and fire once it had operated in that room; plus, of course when this
happens, that is the end of everything."








Testifying with respect to the Salt Lake City fire, Mr. WilUey of NFPA stated:
"In my opinion, these deaths at the Lil-Haven Nursing Home would not have
occurred if automatic sprinkler protection had been provided."
In both the Marietta and Salt Lake City fires, State fire marshals testified
that additional nursing home fires had occurred within a few days of the
tragedies. Ohio Fire Marshal Samuel Sides told the Subcommittee of a fire in
Milford, Ohio (21 days after the Marietta fire), where a nursing home sprinkler
system put out a fire, caused by a defective television set, without loss of life or
major property damage. In a similar statement, Utah Fire Marshal Tanner
reported a fire in a Salt Lake County nursing home days after the Lil-Haven
Nursing Home fire. Sprinklers contained the fire, with only $250 worth of damage.
Many recognized national organizations with expertise in this field have
endorsed the concept of fully automatic sprinkler systems for nursing homes.
Endorsements have come from: (1) The National Safety Council; (2) the Na-
tional Fire Protection Association; (3) the Fire Marshals of North America;
(4) the Joint Commission on the Accreditation of Hospitals; and (5) American
College of Nursing Home Administrators.
The National Commission on Fire Prevention and Control recommended auto-
matic sprinkler protection not only for nursing homes but for all types of units
designed for the elderly. In testimony before the Senate Subcommittee on Hous-
ing for the Elderly, Commission Chairman Richard E. Bland stated: "I submit
to this Subcommittee . that the requirement of complete automatic sprinkler
systems is the available technical solution toward control of fire in housing for
the elderly. I make no distinction between the types of care or housing unit."

HOUSE COMMITTEE ON GOVERNMENT OPERATIONS

The Special Studies Subcommittee, House Committee on Govern-
ment Operations, published a report on December 18, 1974, entitled
"Fire Safety Deficiencies in Nursing Homes." The subcommittee, be-
ginning with the 92nd Congress, 1971, had been engaged in a con-
tinuing study of the problems of the aging. As part of that study,
it had examined the area of fire safety in nursing homes. A series of
hearings in 1971 and 1972 resulted in the 1972 report of the Com-
mittee on Government Operations, "Saving Lives in Nursing Home
Fires."
The committee's 1972 report on fire safety in nursing homes, based
on the subcommittee's hearings in the 92nd Congress, recommended
that all nursing homes be required to have automatic sprinkler systems
regardless of the type of construction.
Additional hearings were held in October 1973, June 1974, and
August 1974. The results of those hearings were analyzed and pub-
lished in the committee's 1974 report. The report concluded that the
requirements of the Life Safety Code have not been effectively
enforced.
The committee's 1974 report reiterated its earlier recommendation
that all nursing homes, regardless of the type of construction, be
equipped with automatic sprinklers.
The Committee's conclusion that there has not been enough improvement in
life safety enforcement since Congress mandated it almost five years ago is based
on a number of reviews and surveys. These were conducted at different times
and by different organizations, but every one of these examinations revealed an
unacceptably large number of life safety deficiencies.
Conclusions reported by the House Committee on Government
Operations included:
The combination of a sparse night staff and of aged residents, 50 percent of
whom are disoriented and 40 percent are partially or totally nonambulatory,







15


renders infeasible the successful evacuation of residents in case a fire occurs at
night.
*f *:
The use of a fire detection alarm system connected to the nearest fire depart-
ment may serve to avoid a total loss of life, but it still does not prevent, as
recent fires have shown, a substantial number of deaths occurring, notwith-
standing an extremely prompt response by the alerted fire department.
p* *
Even fire resistive or protected noncombustible construction does not prevent
fires of contents in such structures. In fact, if such construction is not carefully
executed or if, at the time of a fire, doors are not closed, then such construction
will not Stop a fire from spreading, as demonstrated by the nursing home fires in
Marietta, Ohio, in 1970, and in Buechel, Kentucky, in 1971.
The committee holds that the best means of avoiding multiple death
fires is the construction of complete automatic sprinker systems which
will also transmit an alarm to the nearest fire service.
The committee made the following recommendation:
The appropriate congressional Committees should consider legislation requiring
that, as a condition for eligibility under Medicare or Medicaid or to house the
aged receiving old age assistance payments, each institutional facility for the
aged, no matter what its name and even if not licensed under State law as a
nursing home or related health care facility of some type, must have a complete
automatic sprinkler system, which will also transmit an alarm to the nearest
fire service.

AMERICAN HEALTH CARE ASSOCIATION

Testimony presented for the record at the June 3, 1976, hearing, by
the American Health Care Association (formerly the American Nurs-
ing Home Association) includes the following comments:
Literal adherence to the Life Safety Code in existing buildings is rarely pos-
sible; hence the statutory provision for the granting of waivers. The waiver sys-
tem has been fraught with unbelievable confusion and error, resulting alterna-
tively in non-enforcement of vital code requirements, or the unnecessary ex-
penditure of thousands of dollars and disruption of patient care in nursing homes
due to erroneous application of requirements.
a *
AHCA has long supported sprinkler protection in nursing homes as the most
effective single means of preventing multiple death fires. Dr. Thomas G. Bell,
Executive Vice-President of AHCA, made extensive reference to the value of
sprinklers in testimony before the National Commission on Fire Prevention and
Control in Los Angeles, California, in June 1972. The Association continues to
support sprinklers as an effective means of protection.
a
It is essential that greatly increased fire safety features do not impinge on
the well-being of nursing home residents. The impact on existing nursing homes
can be lessened by concentrating on automatic sprinklers, the one fire safety
measure which years of experience have shown to be effective in controlling a
fire while it is still small.
*? *
All the other fire safety measures now considered to be the primary line of
defense by today's codes should take a back seat to sprinker protection. All
the other Code requirements now forced on nursing homes, have been proven
to be less effective than sprinklers.







16

NATIONAL SAFETY COUNCIL
According to the National Safety Council and the American Nurs-
ing Home Association:
* automatic sprinker systems installed throughout a facility, and not only
in hazardous areas, provide the greatest "safety to life" factor available in the
fire protection field, because they can automatically sound an alarm and im-
mediately start fighting the fire when activated. When activated they are the
most reliable and effective means of fire extinguishment. Other forms of protec-
tive equipment, including automatic alarms, are not effective substitutes for
automatic sprinkler systems.
This quotation is from the "Safety Manual for Nursing Homes and
Homes for the Aged," published by the National Safety Council in
cooperation with the American Nursing Home Association (1962).
The manual continues that "an automatic alarm system is not a substi-
tute for an automatic sprinkler system."

ROANOKE COUNTY FIRE COORDINATOR

A multiple death fire occurred at the Shenandoah Nursing Home
in Roanoke, Va., on June 17, 1976. Although this nursing facility was
not participating in Medicare or Medicaid, it is significant that it did
not have automatic sprinkler protection and that four people were
killed and 28 injured in the fire. The Roanoke County fire coordinator
said the facility was protected with smoke detectors which are less
effective than automatic sprinklers. In his opinion, if the facility had
been sprinklered, there would probably have been not more than one
fatality.

CHIEF OF TIHE CHICAGO FIRE PREVENTION BUREAU
Mr. Francis J. Murphy, Chief of the Chicago Fire Prevention
Bureau, presented testimony before the Subcommittee on Retirement
Income and Employment of the House Select Committee on Aging on
August 12, 1976. The Chief testified from his onsite experience at the
Wincrest fire. He emphasized that because of the high degree of debil-
ity of the residents, special protection is needed:
What this means is that you are talking about one on one when it comes to
care of this type of person. This means that you have to give all the protection,
and the best protection now-not when the fire department comes-but now.
I have heard a lot of controversy over wouldn't a smoke detector, or wouldn't
a heat detector be just as good as a sprinkler head over the bed? Or wouldn't
sprinkler heads be better in the hallway and a smoke detector in the room?
Gentlemen, you are playing with Tinker Toys. This is not right.
You have got to put it (a sprinkler) where the fire is going to happen. And
what does a sprinkler head mean? A sprinkler head, to me-and I have had 44
years in the Chicago Fire Department, from the bottom to the top-what does
it mean? It means that you are standing there with a fireman, a 100 percent
trained fireman, with a two-and-a-half-inch line with a nozzle full of water. All
he has to do is turn it on; and he is there 24 hours a day, 365 days a year.
After the recent fires, a program was enacted in Chicago for sprinklers-100
percent in these types of homes-with smoke detectors. I do not think you could
ask for anything better.






17


CONCLUSION
Based on its analysis of all relevant reports, tests, and studies, the
subcommittee believes that automatic sprinkler systems offer the most
realistic and practical solution to the problem of multiple death fires
in nursing homes.
Fire resistive construction does not insure life safety. Smoke de-
tectors do not put out fires. Nursing home staffs direct their attentions
toward extinguishing fires and not toward removing patients from
danger, and find that they have underestimated the level of impact, the
speed of development, and lethalness to the patients of the fire situation.
The subcommittee believes that automatic sprinkler protection, by
its capability of reducing the basic fire threat, offers the major poten-
tial for the certification of buildings with deficiencies in Life Safety
Code requirements.
The subcommittee recommends that legislation be enacted which
requires all nursing homes participating in Medicare or Medicaid to
be fully protected with 'an automatic sprinkler system. The subcom-
mittee further recommends that no waiver of this requirement should
be made, except in rare cases, and only when the nursing facility
demonstrates that the waiver will not result in an adverse effect on
patient safety and only in cases where application of this requirement
would result in an unreasonable hardship upon the nursing home.





























77-455 0 76 4





































i













CHAPTER 3


THE COST OF AUTOMATIC SPRINKLERS
Gentlemen, you know, your mother, my mother, your father, can
we put a price on their body? There is no money in this world that
can put a price on their body.
So I say let us go the full route. And the best thing that I know
of is a sprinkler system which is 98 percent perfect. So why fool
around and why not go for the best?
-Mr. FRANCIS J. MURPHY, Chief, Chicago Fire Prevention Bu-
reau, Testimony before House Select Committee on Aging,
August 12, 1976 concerning the Chicago nursing home fires
killing 32 elderly persons and injuring 50.
The value of a human life simply cannot be measured in terms of
dollars and cents. Whether it costs a single dollar or millions of
dollars to prevent elderly residents of nursing homes from being killed
in senseless fires is totally irrelevant. We cannot, and will not attempt
to prepare a cost benefit analysis which will compare the cost of an
automatic sprinkler system to the benefit of saving human lives.
The subcommittee believes that our nation's elderly are an irreplace-
able resource; and every reasonable measure should be taken to pro-
tect their lives. The subcommittee is determined to eliminate multiple
death fires in nursing homes. Automatic sprinklers are the solution to
this problem. The only remaining problem is the identification of the
cost of this solution and the determination of how this solution will
be financed.
The cost of automatic sprinklers should not be determined in a
vacuum. The total cost must consider savings on additional fire safety
construction renovations which may be unnecessary; consideration
must be given to the long term reimbursement under Medicare and
Medicaid; and consideration must be given to possible savings on fire
insurance premiums of the building and its contents. And there are
other considerations, including installations in existing and new con-
struction, and whether pipes are to be concealed or exposed.

How MANY NuRSING HOMES WILL BE AFFECTED?
Legislation to require automatic sprinklers in all nursing homes
participating in Medicare or Medicaid will not be an insurmountable
requirement. About half of our nation's 16,500 federally funded nurs-
ing facilities are already required to be fully protected with automatic
sprinkler systems. Under the 1967 Life Safety Code, all nursing homes
must have sprinkler systems except those which are of fire resistive or
1-story protected, noncombustible construction. HEW estimates that
about 8,250 nursing homes, with an average capacity of 80 beds each.
would be affected by legislation requiring automatic sprinkler protec-
tion in all nursing homes.
(19)







20


ACTUAL COSTS REPORTED BY THE GAO

The following analysis of actual sprinkler installation costs was
included in the GAO report, "Federal Fire Safety Requirements Do
Not Insure Life Safety in Nursing Home Fires," June 3, 1976.
The cost of installing an automatic sprinkler system will vary with the size
and type of facility and depend on whether it is of new or existing construction.
However, to examine the impact of requiring all nursing homes to install sprinkler
systems, we are presenting general data obtained regarding the cost of sprinklers.
In February 1976 we discussed the cost of installing a complete sprinkler system
with a representative of the National Automatic Sprinkler and Fire Control
Association. According to the representative, the installation of a complete
sprinkler system, including pumps, valves, piping, and alarms, would cost from
75 cents to $1.25 a square foot while constructing a building. Installation in an
existing building would cost from $1 to $1.50 a square foot. Variables include
whether the pipes were to be concealed or exposed, whether the sprinkler heads
were to be recessed, and the availability of a water supply (that is, is a reservoir
necessary), etc. In April 1976 we obtained data from seven sprinkler installa-
tion companies in the Washington-Baltimore area. According to their estimates,'
a sprinkler system might cost between 50 cents and $1.75 a square foot in an
existing facility. Actual installations during 1975 in four existing nursing fa-
cilities, three in Ohio, and one in Minnesota, showed costs ranging from $393
to $625 a bed, as follows:

Total HEW
Number approved cost of Cost per
of beds Square feet sprinkler system Cost per bed square foot

Facility:
1-- -------------------30 12,100 $18,744 $625 $1.55
2-.--------------34 16,481 20,070 590 1.22
3. ------------------------ 100 35,484 42,850 429 1.21
4-_- -------------150 48,040 58,917 393 1.23

SPRINKEB SYSTEMS MAY COST ABOUT $5.57 A BED EACH MONTH
Using the highest actual cost per bed, the monthly cost of amortizing $625 a
bed over a 20-year period with a 91/4 percent interest rate is $5.57 a bed each
month, or about 19 cents a bed each day.
According to the National Fire Protection Association, automatic sprinkler
heads need replacement at the end of 50 years. However, financing sprinkler sys-
tem installation over a period of more than 20 years does not seem likely. Con-
sequently, our computation shows the monthly payment expected over the term
of a 20-year loan.
Obviously, costs per bed tend to decrease as the number of beds in-
creases. This is because certain larger costs, such as check valves, water
main connections, and alarm hook-ups are necessary for each installa-
tion regardless of bed size. Consequently, when these larger costs are
spread out over more beds, the total cost per bed is reduced.

WHAT Is A SPRINKLER SYSTEM?

According to the National Fire Protection Association, a sprinkler
system for fire protection purposes, is an integrated system of under-
ground and overhead piping designed in accordance with fire protec-
tion engineering standards. The installation includes a water supply,
such as a gravity tank, fire pumps, reservoir or pressure tank and/or
connection by underground piping to a city main. The portion of the
sprinkler system above ground is a network of specially sized or hy-
draulically designed piping installed in a building, structure, or area,








generally overhead, and to which sprinklers are connected in a sys-
tematic pattern. The system includes a controlling valve and a device
for actuating an alarm when the system is in operation. The system is
usually activated by heat from a fire and discharges water over the
fire area.
Hospitals, nursing or convalescent homes are classified as light haz-
ard occupancies. This classification identifies the appropriate stand-
ards for occupancies or portions of other occupancies where the
quantity and/or combustibility of contents is low and fires with rela-
tively low rates of heat release are expected.
Standards have been established by NFPA for sprinkler systems in
nursing facilities and include the following:
The maximum floor area to be protected by one system on any
one floor shall be 52,000 square feet;
Branch lines shall generally not exceed eight sprinklers on
either side of a cross main;
Piping may be of either steel or copper construction, with mini-
mum diameters dependent on the number of sprinklers;
Each system shall be provided with an approved valve, super-
vised by an alarm, to control all sources of water supply;
Ordinary sprinklers must meet temperature ratings of from 135
degrees F to 170 degrees F;
The distance between branch lines and between sprinklers on
the branch lines shall not exceed 15 feet; and
The protection area per sprinkler shall not exceed 200 square
feet.
SPRINKLER COST PER SQUARE FOOT
According to HEW regulations (45 CFR 249.12(b)), "resident bed-
rooms shall have no more than 4 beds. Single resident rooms measure
at least 100 square feet, and multi-resident rooms provide a minimum
of 80 square feet per bed."
In reviewing the NFPA standards, it appears that a per bed cost
analysis of sprinkler installations may overstate total costs. This is
the case because it may not be necessary to have one sprinkler per bed.
The capacity of sprinkler protection is 200 square feet per sprinkler,
which area could easily accommodate two beds. Consequently, in bed-
rooms containing four beds, a total of two sprinklers may be sufficient
protection.
In order to evaluate total costs in a realistic light, it appears square
footage estimates will result in more accurate projections because this
is the basis for cost estimates by sprinkler installation companies.
From the table prepared by GAO on actual installation costs, there
does not seem to be the same relationship of cost per square foot 'as
there was with cost per bed. Significantly, the facility with the lowest
cost per bed did not realize the lowest cost per square foot.
The average costs per square foot were shown, by GAO, to range
from $1.21 to $1.55. The GAO also reported estimates from sprinkler
installation companies of costs per square foot ranging from 50 cents
to $1.75 for an existing building. The analysis here will restrict itself
to existing buildings since these are the facilities most affected by a
change in legislation to require sprinklers. In addition, installation
cost in new construction is known to be less expensive. Consequently,






22


for analysis purposes, a high estimate of $1.75 per square foot and a
low estimate of $1.21 per square foot will be considered. The estimate
of 50 cents per square foot will not be used in order to be as realistic
as possible.
COST PROJECTIONS ON A SQUARE-FOOT BASIS
According to HEW figures, about 8,250 nursing homes, with an
average of 80 beds each, will require automatic sprinklers if such
legislation is enacted. Considering these figures, the following analysis
results:
1. Eighty beds per facility multiplied by 80 square feet per bed
results in about 6,400 square feet of bedroom area per facility, on the
average.
2. Assuming that each facility will have an area equivalent to three
times the sleeping area for resident activities, as well ascorridors, stor-
age areas, and administrative areas, an additional 19,200 square feet
per facility should be considered for sprinkler protection.
3. The total estimated area, per average facility, requiring sprinkler
protection is thus, about 25,600 square feet. This total appears con-
sistent with the actual square footages reported by the GAO sample of
actual installations.
4. The high and low range cost estimates, per facility, can be esti-
mated from $30,976 at $1.21 per square foot to about $42,800 at $1.75
per square foot. These totals appear consistent with actual costs re-
ported by the GAO sample of actual installations.
5. Considering that 8,250 facilities will need sprinkler protection, it
can be projected that the total expenditure may approximate from
$256 million to $353 million on a national basis.

HEW AND NATIONAL BUREAU OF STANDARDS COST ESTIMATES
At hearings on June 3, 1976, HEW estimated that the total cost
of installing sprinklers in all nursing homes participating in Medi-
care and Medicaid would be about $412.5 million. This HEW estimate
was based on multiplying 8,250 facilities by 80 beds per facility for
a total of 660,000 beds multiplied by $625 per bed (the highest cost
per bed reported by GAO) to equal $412.5 million.
The fallacy of this analysis is that HEW used the number of beds
as the basis of their projections. This, as was shown previously, can
result in an overstatement of total costs.
HEW also testified that their best estimate of the cost per square
foot for sprinkler installations was about $2.30. This, HEW pointed
out, would result in a per bed cost of $927 and a total cost of $611.8
million.
The HEW computation obviously is based on the assumption that
each bed represents a total of 403 square feet of area in need of sprinkler
protection. This would include the 80 square foot minimum per bed
plus four times this area for community and administrative areas.
The fallacy here is that both the costs per square foot, and total areas
are overstated. The highest estimate obtained by GAO is $1.75 per
square foot and the highest 'actual cost for installation, as shown by the
GAO table is $1.55 per square foot. HEW has supplied no basis for






23


its cost estimate of $2.30 per square foot. In addition, the 403 square
foot area per bed appears too high when compared to the four actual
cases cited by GAO. In a 100 bed facility the actual square footage
area was shown as 35,484, while HEW would estimate a facility of
this size to have 40,300 square feet for their cost projection purposes.
The mathematical average of the GAO sample shows that an average
total area per bed approximates 357 square feet. Using the 'highest cost
estimate reported by the GAO, $1.75 per square foot, this projection
(357 square feet per bed multiplied by $1.75 per square foot, multiplied
by 660,000 beds), results in a total national cost of $412.3 million.
The HEW estimate of $2.30 per square foot with 403 square feet
per bed results in a total national cost of $611.8 million, which re-
flects a total variance of $199.5 million. The high cost estimate of $2.30
per square foot results in an overstatement of $221.65 per bed, or about
$146.4 million of the total overstatement. The high area estimate
results in an overstatement of $80.50 per bed, or about $53.1 million
of the total overstatement. This HEW estimate simply overstates
both cost and area and is not a sound basis upon which to project the
total national cost of requiring nursing homes to install automatic
sprinklers. Consequently, considering that the cost per square foot
is $1.75, and the square footage per bed is 357 rather than 320 (as
previously estimated) then the highest estimate of cost would be
$624.75 per bed for a total of $412.3 million on a national basis.
HEW further estimated that at 1978 prices, the cost of installing
sprinkler systems will approximate $3.00 per square foot.
The fallacy here is simply that HEW -has presented no basis for
suggesting that costs will increase to this degree. Subcommittee staff
investigators found that sprinkler-installation companies believe that
competition will keep costs down.
The National Bureau of Standards projects the cost of automatic
sprinklers at $625 million. This projection is based on a total of 1.3
million nursing facility beds available in the United States, of which
only .3 million are already protected by automatic sprinklers. The
remaining 1 million beds were multiplied by the highest GAO figure
of $625 per bed resulting in an estimate of $625 million.
The fallacy of this estimate is obvious. The determination of cost for
sprinkler installations should be based on square footage, not beds,
as previously stated. Further, there is no logic in the Bureau of Stand-
ard's estimate of 1 million beds in unsprinklered facilities. HEW,
the agency which administers both Medicare and Medicaid, has esti-
mated that only about 660,000 beds are in facilities not protected by
automatic sprinklers. HEW stated that about half of all nursing
facilities are already required to have automatic sprinkler systems.
Half of the 1.3 million beds would approximate the 660,000 beds HEW
estimates are currently not protected by automatic sprinklers.

SUBCOMMITTEE OBSERVATION
From the cost data presented to the subcommittee, it is estimated
that a national commitment for automatic sprinklers in all nursing
homes would cost from $256 million to $412.3 million. The range re-
sults because each installation differs from the other; and consideration






24


of such factors as whether pipes are to be exposed have some cost im-
plications which cannot be readily identified.

DIRECT FEDERAL LOANS ARE NECESSARY
The congressional commitment to assist nursing homes install auto-
matic sprinklers through the federally insured loan program of 1973
has not resulted .in the issuance of a single loan anywhere in the coun-
try. The GAO reported that the loan insurance program was simply
not operational because of the governmental red tape nursing homes
were subjected to, and the lack of incentives over commercial financing.
The Congress enacted Public Law 93-204, on December 28, 1973,
which was intended to provide insurance to assist nursing homes install
sprinkler systems. This law was enacted on the basis of the recom-
mendation of the House Committee on Government Operations.
Bureaucratic tangling between HEW and HUD, which have joint
authority over this program, together with a "Catch-22" situation of
excessive processing time and a prohibition against loan insurance
after work has begun, are largely responsible for the failure of the
program.
The Subcommittee on Health and Long-Term Care, based on its
analysis of the problems, concludes that a loan insurance program is
not the answer. The congressional commitment for fire safe nursing
homes must be followed through with direct loans, not grants or
insurance, to insure the availability of funds.
Under the proposal to make funds available to nursing homes on
a direct loan basis for the installation of sprinkler systems, three
factors must be considered: inflation, interest, and present value.
The present value factor is the actual dollar cost to be paid cur-
rently for sprinkler installations. The dollars paid today are estimated
from $256 million to $412.3 million. This will be the amount the Fed-
eral government will loan to nursing homes which will in turn be
paid for the installation of sprinkler systems. These present values
are unaffected by either inflation or interest. This will be the full
amount loaned by the government.
Interest is a factor in considering the amount to be paid back to
the government by the nursing homes. The interest rate under con-
sideration is 6 percent. The subcommittee proposal would require nurs-
ing homes to repay the loan over a 20 year period with interest not
exceeding 6 percent annually. This rate approximates the Federal
government's cost. of borrowing the funds, considering the interest
paid by the government on Series E savings bonds. This results in the
government incurring no long-term dollar cost in loaning the money
to nursing homes because the government's cost of borrowing these
funds has been returned. The nursing homes are receiving the benefit
of being able to borrow the funds at an interest rate which is less
than what would be charged by banks and other financial institutions.
Inflation is a factor which must be considered in the loss of dollar
value over the repayment period. Although the present value of the
dollars paid out are certain, the present value of the dollars paid back
over 20 years is uncertain. This is the case because the rate of future
inflation is an unknown. However, a factor for inflation must be in-
cluded in the analysis. The Congressional Research Service of the






25


Library of Congress has determined the projection of the future in-
flation factor over the next 15 years for fixed investments for non-
residential equipment at a rate of about 5.8 percent. This rate estimates
the annual increases expected in the cost of this type of investment.
The Library of Congress has identified the projected rate of overall
inflation to be about 5.3 percent. This means that if this rate holds,
the purchasing power of the dollars spent today will be reduced by
5.3 percent each year over the loan payback period. Very simply trans-
lated, the only cost to the Federal government that will result from
the proposed loan program will be the dollar value lost as a result of
inflation. Although there is no certain method of determining if this
inflation rate will remain constant, it should be recognized that all
Federal loan programs are subject to the same inflation factor. To
protect against this inflation cost, the government would have to
charge a higher interest rate which may not be in the public interest
for this program.

MEDICARE AND MEDICAID REIMBURSEMENT
Nursing facilities participating in either Medicare or Medicaid will
be reimbursed for part of the cost of automatic sprinkler systems
through interest and depreciation.
Depreciation is the allocation of the cost of sprinkler systems over a
period of time. For example, a $40,000 system depreciated over 20 years
will result in an annual charge to depreciation of $2,000. Both Medicare
and Medicaid reimburse for all allowable costs associated with the use
of the facilities. Depreciation is an allowable cost and will, therefore,
be reimbursed to the nursing home.
In the case of nursing homes with all Medicare or Medicaid resi-
dents, the sprinkler system will cost nothing to the owners since Medi-
care and Medicaid will reimburse the facility in full. Interest is also
included as an allowable cost and will be reimbursed by the Medicare
and Medicaid programs.
In the case of nursing homes with all Medicare or Medicaid resi-
dents, each month they will receive full reimbursement for their
monthly payments for the sprinkler system loan, including interest.
In facilities with some private paying residents, Medicare and Medic-
aid will only pay their proportionate shares of the nursing home costs.

SAVINGS ON UNNEEDED CONSTRUCTION MODIFICATIONS
Many nursing homes were built long before the 1967 Life Safety
Code was published. Many facilities were originally built as apart-
ments, private houses, hotels, and other buildings.
While these buildings met the building and fire codes of the 1930's,
1940's and 1950's, they may not meet the 1967 Life Safety Code. Con-
sequently, in order for these nursing homes to meet the requirements
for Medicare and Medicaid certification, major construction renova-
tions may be required. For example, the Life Safety Code requires
that "no existing building shall be converted to a hospital, nursing
home, or residential-custodial care institution unless it complies with






26


all requirements for new institutional buildings." Some of the Life
Safety Code requirements for building construction include:
Corridors shall be separated from use areas by partitions having a fire resistive
rating of at least one hour;
Interior finish of walls and ceilings of any room shall be Class A;
Institutional occupancies two or more stories in height shall have enclosure
walls of noncombustible materials having a fire resistance rating of at least two
hours around stairways, elevators, chutes, and other vertical openings between
floors;
Any smoke partition shall have a fire resistance rating of at least 1 hour.
In many cases, facilities built years ago were not constructed to meet
the above standards. However, all facilities must meet the construc-
tion standards of the Life Safety Code for Medicare and Medicaid
certification.
Thousands of dollars may be spent by nursing home owners in order
to make construction modifications in order to meet the Life Safety
Code standards. These many thousands of dollars may be totally un-
necessary if the facility is protected with a sprinkler system. Both the
Wincrest and Cermak nursing homes fully met the construction stand-
ards of the Life Safety Code, and still 32 people were killed because
of fire.
Gage-Babcock and Associates, Inc., a fire protection engineering
firm, reported on both the Wincrest and Cermak fires that fire resistive
construction did not contain the fire any better than protected wood
frame construction would have. Based on actual fire tests, the engi-
neering firm reported that with automatic sprinklers, the fire does not
last long enough to be affected even by combustible wall paneling and
ceiling tiles.
At the June 3, 1976, hearing, representatives from the General Ac-
counting Office testified that, in the cases of tlhe Wincrest and Cermak
fires, time was the critical factor. Within minutes of the fires, a lethal
environment was created. It was not a matter of withholding the fire
for a period of hours, but rather the danger was measured in terms
of seconds and minutes.
A witness to the fire at Wincrest, the Reverend William Pollard,
exemplified the speed with which the fire took place. He said at the
subcommittee hearing that "very, very quickly the white smoke turned
to black smoke and it began to descend on us until we could no longer
see the fire, until we could no longer breathe."
The subcommittee believes that with automatic sprinklers, the safety
of patients would not seriously be compromised by "trading-off" the
strict enforcement of the various hour ratings of building construction
for automatic sprinkler installation. Consideration should be given,
for existing facilities, to not requiring major construction renovations
when the facility is fully protected with an automatic sprinkler system.
HEW has authority, under existing law, to waive any Life Safety
Code standard if enforcement of such standard would result in an
unreasonable hardship on the facility, but only if such waiver will
not adversely affect the safety of the patients. The subcommittee be-
lives that with an automatic sprinkler system there will not be an
adverse effect on patient safety if certain construction standards are
waived. HEW should give serious consideration to granting certain







27


construction standards waivers in facilities where complete automatic
sprinkler protection is provided.
The subcommittee believes that facilities can save many thousands
of dollars in unnecessary construction renovations and upgrade their
level of fire protection by installing automatic sprinkler systems.

POSSIBLE SAVINGS ON FIRE INSURANCE

As pointed out in the GAO report, savings are possible on fire
insurance premiums on both the building and its contents when auto-
matic sprinklers are installed. The GAO reported:
Although fire insurance rates vary among States, savings are possible on both
building coverage and contents insurance when nursing facilities are protected
by automatic sprinkler systems. We obtained information on the general rates
in Maryland and Washington, D.C., and found that savings of about 30 percent
are possible on building coverage and 50 percent on contents insurance.
According to a representative of the Insurance Services Offices of Maryland,
a rating bureau under the jurisdiction of the State Insurance Commission, fire
insurance premiums would be less because of the installation of automatic
sprinklers in nursing facilities. With regard to fire insurance on the building,
he said the rate per $100 of insurance is about 8 cents without sprinklers in
ordinary construction and about 6 cents with sprinklers, for a reduction of about
25 percent. In protected wood frame construction, he said the fire insurance rate
per $100 of insurance is about 16 cents without sprinklers and about 11 cents
with sprinklers, for a savings of about 30 percent.
According to a representative of the Insurance Rating Bureau of Washington,
D.C., building contents insurance premiums could be reduced by as much as
50 percent by installing automatic sprinkler systems. He quoted rates for
nursing facilities of frame, ordinary, and fire resistive construction. He stated
that in buildings of frame construction, the building contents insurance rate per
$100 of insurance is about 71 cents without sprinklers and 45 cents with sprin-
klers, for a reduction of about 37 percent. In ordinary construction, he said
the building contents rate per $100 of insurance is about 50 cents without sprin-
klers in contrast to about 30 cents with sprinklers, for a savings of about 40 per-
cent. For fire resistive construction, he quoted a building contents insurance
rate per $100 of insurance of about 20 cents without sprinklers and 10 cents
with sprinklers, for a reduction of about 50 percent.
To illustrate the annual savings on fire insurance premiums due to the instal-
lation of an automatic sprinkler system, consider a hypothetical example of a
protected wood frame facility insured for $500,000 on the building and $100,000
on the contents. Without a sprinkler system the facility would pay about $800
for building insurance at 16 cents per $100 of coverage and about $710 for con-
tents insurance at 71 cents per $100 of coverage, for a total annual cost of about
$1,510. With a sprinkler system the facility would pay about $550 for building
insurance at 11 cents per $100 of coverage and about $450 for contents insurance
at 45 cents per $100 of coverage, for a total annual cost of about $1,000. In this
hypothetical example, the installation of an automatic sprinkler system would
result in annual savings for fire insurance in excess of $500.

NEW CowNSTRUCTIoN

The subcommittee believes that no new nursing facility should be
built without automatic sprinkler protection. The cost of sprinkler
installation in new construction ranges from 75 cents to $1.25 per square
foot according to GAO. Because of the benefits of automatic sprinklers
over various other construction standards, every future nursing home
should be fully protected with an automatic sprinkler system. The
possibility of waiving certain construction standards in order to "trade-
off" costs should be given serious consideration by HEW and the
States in enforcing provisions of the Life Safety Code in new
construction.






28


ARGUMENTS CONCERNING THE PRIORITY OF THE HEALTH DOLLAR
At the June 3, 1976 hearing, HEW presented testimony which
pointed out the many problems facing residents of nursing homes
related to the quality of health care. Dr. Faye G. Abdellah, Special
Assistant to the Undersecretary for long-term care, stated that:
In terms of the needs of individuals in facilities are the basic requirements of
health and nutrition, for example the need for occupational therapy, and other
things we want elderly individuals to receive in long-term care facilities. Their
needs must be weighed against the overall need for sprinklers. The investment
for sprinklers needs to be weighed in terms of the total needs of the individuals
in these facilities and arriving at a balance of both safety and health requirements.
The subcommittee agrees wholeheartedly with Dr. Abdellah. How-
ever, we fail to see the conflict of goals. Currently, over $9 billion an-
nually is spent for care in nursing homes. Federal standards for health
care have been established and the Federal Government is paying 100
percent of the salaries of inspectors to insure that the nursing homes
are providing care in accordance with the standards.
Both Medicare and Medicaid are paying nursing homes on a cost-
related basis. In other words, they are reimbursed for the cost of
providing health care.
The subcommittee believes that if nursing home residents are not
receiving proper care, even though the cost is over $9 billion annually
for this care, then either the HEW standards for proper care are inade-
quate or the enforcement of the standards is inadequate. We are aware
of serious deficiencies in the enforcement of Federal standards by State
inspectors and this subcommittee plans to continue its oversight re-
sponsibilities in this area.
The subcommittee fails to see the logic of any argument which states
that the investment for automatic sprinklers should be deferred or
eliminated because these funds would take away from other health
care funds. The total fiscal 1977 appropriation for the Department of
HEW exceeds $45 billion. A very large sum of money is continually
being spent on health care by the Federal Government each and every
year, and the cost of automatic sprinklers is a one-time loan spread out
over a 20-year period, with no direct long-term cost to the Federal
Government. The subcommittee does not agree that the investment in
automatic sprinkler systems is going to reduce the amount of Federal
money spent on health care.
The subcommittee believes the cost to facilities (19 cents per patient
per day over 20 years) is low enough to be extremely feasible econom-
ically and is badly needed.
The subcommittee believes that a safe environment is of critical
importance in providing adequate health care. As was pointed out at
the June 3, 1976 hearing, fire safety is one of the single most important
psychological factors leading to the emotional well-being of an
elderly person in a nursing home. Nursing home residents in facilities
visited by subcommittee staff related "fear of a fire" as one of their
greatest concerns, as virtually all residents had seen television or news-
paper accounts of the many recent tragic fires.












CHAPTER 4


OTHER APPROACHES TO FIRE SAFETY
Research at the National Bureau of Standards has been in progress
as a result of recommendations made in the December, 1972 GAO re-
port, "Study of Health Facilities Construction Costs." This research
has led to the identification of other protection systems which some
researchers believe could provide an equal level of life safety as full
sprinkler protection in health care facilities. Two of these potential
systems are:
1. Smoke detection capability in each patient room combined with a
limited automatic sprinkler system: an automatic sprinkler head
placed in the corridor opposite each patient room door.
2. An automatic door closer mechanism combined with a detection
unit for each patient room.
These items represent two potential systems that have been identi-
fied in the preliminary work done at the National Bureau of Stand-
ards. It is estimated, by the researchers, that a typical fire growth and
development scenario within a patient room provides a five minute pe-
riod of time for action from the time of open flaming to room flash-
over; and that smoke detectors in the patient room would respond to
a fire in less than two minutes into its growth. This would allow staff
over three minutes to rescue patients within the room of origin, and
to take initial actions that might mitigate the full growth and develop-
ment of the fire within the room. Thus, the detection systems in both
of the proposed alternative fire protection approaches could provide
a higher level of potential life safety for patients within the room of
origin.
In addition, according to the Bureau of Standards researchers, the
automatic sprinkler protection provided in the corridor, with heads
located opposite each patient room door, would provide an energy bal-
ance mechanism which could prevent fire from the room of origin en-
tering into the corridor and into the remainder of the facility.

THE SMOKE DETECTOR ALTERNATIVE
Although this alternative has merit in the early detection of a fire,
the three minutes deemed to be available for evacuation of residents
and fire prevention actions may not be sufficient to insure life safety.
Too much reliance on human action is required. As was pointed out at
both the Wincrest and Cermak fires, no deaths occurred in the rooms of
origin; and the environments became deadly in a few short minutes.
There was no indication, at these fires, that any delay in the identifica-
tion of the fires contributed to the loss of life.
Another fallacy of this alternative is the reliance on a sprinkler sys-
tem outside the room of origin to prevent the spread of fire. Current
(29)






30


standards require that patient rooms be separated from the corridor
by 1-hour fire resistive construction. This would require that if the
door is closed, the fire must become so intense that sufficient heat was
generated through the wall to activate the sprinkler in the corridor.
This would mean that an equal or perhaps greater degree of heat would
be generated toward patient rooms on either side of the fire room and
to the floor above. Consequently, before the sprinkler in the corridor
would be activated, the fire may have spread to adjacent patient rooms,
also without sprinkler protection. This alternative still relies on hu-
man action to put out the fire.
Another fallacy of this alternative is that by the time the sprinkler
system in the corridor was activated, the room of fire origin would
probably be burning out of control. Even activation of the sprinkler
would not extinguish the fire in the room of origin nor prevent its
spread to adjacent rooms through walls, floor, or exterior windows.
The sprinkler would only prevent the fire from spreading through the
door and would have little, if any, effect on extinguishing the flames.
The corridor sprinkler may have little effect on smoke propagation.
Another fallacy of this alternative is cost. The larger costs of in-
stalling a sprinker system relate to check valves, connections to water
main, and alarm hookups. Very little cost savings will result from not
extending branch piping into patient rooms from the cross main pipe.
Even this alternative relies on the installation of an automatic sprinkler
system, which includes the larger cost items and labor expense. In
addition, according to the Congressional Research Service of the
Library of Congress, smoke detectors are relatively expensive. The
Library reported that equipment and installation costs, including costs
for fire alarm equipment, stations, gongs, and smoke detector units
would be as follows:
1-story, 25 bed facility-------------------------------------------- $10,000
2-story, 50 bed facility ----------------------------------- 20,000
Multistory, 100 bed facility -------------------------------- 50, 000
These figures indicate that smoke detectors could cost from $400 to
$500 per bed.

THE AUTOMATIC DOOR CLOSER ALTERNATIVE
The other proposed alternative solution of the Bureau of Standards
researchers would provide no direct extinguishment mechanism for the
fire. Closing the door has been shown to be effective in fire containment
and in preventing the spread of smoke and gas. The automatic door
closer system, which provides a smoke detection device to automatically
close the door and sound an alarm, provides one additional feature: a
higher level of redundancy against human action taken during the fire.
The Bureau's investigation of the two Chicago nursing home disasters
determined that doors on patient rooms involved in fire were closed by
the staff early in the fire but were then repeatedly reopened by staff
action in attempting to extinguish the fire. The doors were finally left
open due to the heat and smoke conditions within the room of origin,
which made manual operation of the doors impossible. The automatic
door closer mechanism could, with a degree of reliability significantly








greater than dependence on human action, still be capable of closing a
door late in a fire even after human action had taken place leading to
the reopening of the door. The Bureau of Standards estimates the cost
of door closer to be between $400 and $500 per door in anl existing
building: more if the devices on all doors are interconnected so as to
either sound an alarm or so that all doors will operate if one detects
smoke.
The primary problems of the automatic door closer alternative are
that it is costly and does nothing to extinguish the fire. Further, there
is no reliable data on either the long term reliability or maintenance
problems associated with these somewhat complex door closer. They
represent a new technology and in all probability there will be some
problems. This type of device has been on the market in modest num-
bers for 5 to 10 years and the limited experience has been quite
variable. At this time, according to the Bureau of Standards, there is
no data regarding the capability of the door closer on the room of fire
origin if the door should be opened during the fire sequence in attempts
to rescue or fight the fire. Warping the door or bending of the hinges,
however, would be expected to be a significant factor on reclosing the
door.
An option to smoke operated door closer is self-closing doors. Self-
closing doors may, for all intents and purposes, be impractical in any
facility where doors close as soon as the person passing through lets
loose of the door or its handle. The use of these doors by wheelchair
patients may be all but impossible.
Another fallacy of this alternative is that there may be some reduc-
tion in the safety of immobile occupants in the room of origin due to
the potential interference with rescue operations should the door auto-
matically close before the patients are removed. This may also result in
a problem for people in wheelchairs and semiambulatory people. Auto-
matic door closer generally work on an electro-magnetic principle.
However, wheelchair patients can easily bump into the doors causing
them to close and possibly causing injury. In addition, furniture,
meal tray carts, or wheelchairs could be placed in front of the doors
rendering the closing device useless in case of fire. In addition, elderly
patients could be injured, in case of fire, if they are hit by a closing
door. This alternative still relies on human action to put out the fire.

SUBCOMMITTEE OBSERVATION
The alternatives to complete automatic sprinkler protection proposed
by the National Bureau of Standards do not provide for the extin-
guishment of fires or serve to prevent multiple death fires in nursing
homes. The first alternative requires substantial expenditures and uses
the benefits of automatic sprinkler protection improperly by not
placing the sprinklers over the fire. Although a combination smoke
detector system in conjunction with complete automatic sprinkler pro-
tection would provide the highest level of safety, the cost of this com-
bination would be unreasonable. The subcommittee holds that prompt
extinguishment of a fire is the solution to preventing multiple deaths.
Complete automatic sprinkler protection is the most cost effective
method of eliminating multiple death fires in nursing homes.
















CHAPTER 5


WAIVERS FROM FIRE SAFETY REQUIREMENTS
The Social Security Act allows HEW to waive specific provisions
of the Life Safety Code which if rigidly applied would result in un-
reasonable hardship upon a nursing home, but only if such waiver will
not adversely affect the health and safety of the patients.
The subcommittee believes that in cases where automatic sprinkler
protection is provided throughout a facility, waivers from certain con-
struction requirements of the Life Safety Code would not result in an
adverse affect on patient health and safety. Consequently, one of the
prerequisites HEW should require, before waivers from Life Safety
Code provisions are granted, is complete automatic sprinkler protec-
tion throughout the facility.

SPRINKLER REQUIREMENT WAIVERS
A requirement that all nursing homes, regardless of construction,
be fully protected with an automatic sprinkler system, may, in certain
cases, present an unreasonable hardship on a nursing facility. For ex-
ample, nursing homes of 15 beds or less, may find that if they are
forced to install sprinkler systems, the financial burden would bank-
rupt the facility. The subcommittee wants to protect lives from
multiple death fires, and not force the closure of nursing facilities.
Consequently, HEW should consider waivers from the sprinkler re-
quirement, in those cases where an unreasonable hardship would be
placed on a nursing facility, but only if such waiver will not adversely
affect patient health and safety.
In its March 18, 1975 report, entitled, "Many Medicare and Medic-
aid Nursing Homes Do Not Meet Federal Fire Safety Requirements,"
the General Accounting Office reported that HEW was not properly
enforcing the waiver provision in cases of waivers from the automatic
sprinkler requirement. The GAO reported that in 79 percent of the
cases, waivers were granted from the sprinkler requirement even
though the facilities did not meet the requirements for such waiver.
The GAO recommended that HEW establish requirements to be met
by a nursing home, before the waiver is issued, in order to assure that
the waiver would not adversely affect the health and safety of the
patients.
The GAO recommended in its June 3,1976 report., entitled, "Federal
Fire Safety Requirements Do Not Insure Life Safety In Nursing
Home Fires," that "because of HEW's improper treatment of its exist-
ing waiver authority, and its lack of acceptance of the need for waiver
standards for all types of construction, the Congress should require
that HEW establish waiver standards which must be rigidly enforced
(33)






34


before a waiver may be granted to any facility, regardless of con-
struction type."
The subcommittee agrees with the GAO recommendation. It is too
important to protect the lives of nursing home residents from the
dangers of fire to allow lax enforcement of fire safety standards. The
subcommittee offers the following suggestions to HEW as the mini-
mum requirements which must be met by any facility, regardless of
construction, before a waiver from the automatic sprinkler require-
ment should be issued:
Among the requirements which HEW should take into account:
1. Smoke detectors must be located in all patient rooms and through-
out the facility and connected to an alarm which will, notify the
nursing home staff and the local fire department.
2. Smoke barriers and automatic closing smoke doors shall be
installed in accordance with the Life Safety Code standards.
3. Patient rooms shall be separated from each other and all other
areas by construction having at least a 1-hour fire resistance rating.
4. All other Life Safety Code requirements, including the auto-
matic extinguishment requirement for hazardous areas, shall be met.

SUBCOM MITTEE OBSERVATION
The subcommittee recognizes that in some cases, a requirement to
install an automatic sprinkler system could result in unreasonable
hardships, and some facilities may be unable to comply with a require-
ment for automatic sprinklers. Since such factors may exist, the waiver
provision of the Social Security Act should be applied only in specific
cases and only when approved by personnel qualified in fire protection
engineering. HEW policy should be to make every effort to avoid
waivers and assure installation of complete sprinkler protection in all
nursing hoanes.













CONCLUSIONS


On the basis of extensive research, a joint hearing with the Senate
Subcommittee on Long-Term Care, and the investigation conducted
by the General Accounting Office, the Subcommittee on Health and
Long-Term Care makes the following conclusions:
1. In spite of previous congressional efforts to insure life safety in
nursing homes, multiple death fires continue to occur.
2. Experts agree that automatic sprinkler systems are the most effec-
tive known method to eliminate the problem of multiple death fires in
nursing homes.
3. The two nursing home fires in Chicago resulting in multiple
deaths, and other fires elsewhere, demonstrate conclusively that fire
resistive construction does not prevent multiple death fires.
4. Actual fire tests, contracted by the Department of Health, Edu-
cation, and Welfare, have concluded that fire resistive construction
provides no significant life safety benefit in buildings protected by
automatic sprinklers.
5. Adequate time is not available to safely evacuate residents in cases
of fire. Nursing homes must be made capable of protecting residents
without relying on evacuation.
6. Prompt response time by local fire departments may prevent the
total destruction of the building and reduce fire loss, but it cannot
prevent multiple death fires in nursing homes.
7. In addition to confining and extinguishing the fire, automatic
sprinklers will reduce and control the total amount of smoke and heat
produced by a fire and thus contribute to preventing life loss.
8. The National Bureau of Standards has reported that full protec-
tion by automatic sprinkler systems is the best known way to prevent
disastrous multiple death fires.
9. Self-closing doors are not a practical solution to preventing mul-
tiple death fires because they provide no direct extinguishment mech-
anism and because they may close and cause injury or present a prob-
lem to occupants of the room.
10. Smoke detectors only notify that there is a fire and provide no
means of extinguishment nor control of fire and smoke.
11. There has never been a multiple death fire in a nursing home
fully protected with an automatic sprinkler system.
12. Half of the nation's 16,500 Medicare and Medicaid nursing
homes are not fully protected with automatic sprinkler systems.
13. Numerous nationally recognized organizations recommend full
automatic sprinkler protection in all nursing homes.
14. The current Federal loan insurance program for fire safety
equipment has been totally ineffective because of delays from bureau-
cratic tangling between HEW and HUD, and because of a require-
ment that loans cannot be approved after work has begun.
(85)












RECOMMENDATIONS


The Subcommittee on Health and Long-Term Care of the House
Select Committee on Aging makes the following recommendations,
based on the results of investigations by the subcommittee, years of
study and research by numerous individuals and organizations, and
conclusions and recommendations made by experts in the fire protec-
tion industry:
1. The Congress should immediately enact legislation which will re-
quire that all nursing facilities participating in Medicare or Medicaid
be fully protected with automatic sprinkler systems. Such systems
should meet the standards established by the National Fire Protection
Association in its publication NFPA No. 13, "Standards for Sprinkler
Systems."
2. The Congress should enact legislation providing a revolving fund
by which the Department of Health, Education, and Welfare may
make direct loans to nursing facilities for the purchase, construction,
and installation of automatic sprinkler systems. Such loans should
provide for interest at a rate not to exceed 6 percent.
3. The Congress should enact legislation requiring the Department
of Health, Education, and Welfare to establish minimum requirements
which must be met by any nursing facility before a waiver from the
automatic sprinkler requirement is issued. These minimum require-
ments should reasonably assure that a waiver from the automatic
sprinkler requirement would not. adversely affect the health and safety
of the patients; and that such waiver would only be issued when en-
forcement of the sprinkler requirement would result in an unreason-
able hardship on a facility.
4. All States should take action to require complete automatic
sprinkler protection in all group homes caring for the elderly, whether
or not certified for Medicare or Medicaid. This requirement should ex-
tend to all forms of institutional elderly housing regardless of their
institutional classification, whether skilled nursing facilities, inter-
mediate care facilities, nursing homes, homes for the aged, or custodial
facilities.
(36)















APPENDIXES



Appendix I: RELATED REPORTS ON FIRE SAFETY

1. Report of the Comptroller General of the United States, "Federal Fire Safety
Requirements Do Not Insure Life Safety In Nursing Home Fires," June 3,
1976.
2. Report of the Comptroller General of the United States, "Many Medicare and
Medicaid Nursing Homes Do Not Meet Federal Fire Safety Requirements,"
March 18, 1975.
3. Report of the House Committee on Government Operations, "Fire Safety
Deficiencies In Nursing Homes," December 18, 1974. House Report 93-1627.
4. Report of the American Health Care Association, "Fire Test in a Nursing
Home Patient Room," June 1975.
5. Report of the panel appointed by the Mayor of Chicago to investigate the
Wincrest Nursing Home fire, May 1976.
6. Report of the National Fire Protection Association on its analysis of the
Wincrest and Cermak Nursing Home fires, April 1976.
7. Report of the Senate Subcommittee on Long-Term Care, "The Continuing
Chronicle of Nursing Home Fires," August 1975. Senate Report 94-00.
8. Report of the House Committee on Government Operations, "Saving Lives in
Nursing Home Fires," August 9, 1972. House Report 92-1321.
9. Report of Gage-Babcock & Associates, Inc., on the Wincrest and Cermak
Nursing Home fires, March 1976.
10. Report of the Department of Commerce's National Bureau of Standards on
"Proposed Changes to Nursing Home Standards Resulting from the Recent
Chicago Fires," March 25,1976.
11. Report of the National Commission on Fire Prevention and Control "America
Burning," May 4,1973.
(37)






38


Appendix II: PENDING CONGRESSIONAL LEGISLATION
TO REQUIRE AUTOMATIC SPRINKLER SYSTEMS IN
NURSING HOMES


94-IT CONGRESS
21 SESSION


H. R. 14406**


IN TIHE HOUSE OF REPRESENTATIVES
JUNE 16, 1976
Mr. PEPPER introduced thle following bill; which was referred jointly to the
Coiiinittees on Ways and Means and Interstate and Foreign Commerce




A BILL
To ameiid the Social Securiity Act to require automatic sprinkler
systems in all nursing facilities aind intermediate care facili-
ties certified for participation in the medicare or medicaid
prograin, and to provide for direct low-interest Federal loans
to assist such facilities in constructing or purchasing anld
installing automatic spriniikler systems.
1 Be it enacted( by the S(nate and House of Represn(tla-
2 fires of the United States. of America in Conlgress asscmbfJd,
3 That section 1861 (j) of the Social Security Act is
4 amended-
5 (1) by striking out "except that the Secretary may
6 waive" in paragraph (13) and inserting in lieu thereif
I

**Cosponsored as of September 16, 1976, by 89 Members of
the House of Representatives.






39


2
1 "except that (subject to the last paragraph of this sub-
2 section) the Secretary may waive"; and
3 (2) by adding at the end thereof the following new
4 paragraph:
5 "No waiver of or exemption from the requirement of the

6 Life Safety Code that all nursing homes be fully protected
7 on all floors with an automatic sprinkler system shall be
8 allowed under paragraph (13) with respect to any facility
9 on the basis of construction classification; and no such waiver
10 shall be granted on any other basis unless a certification hlias
11 been made to the Secretary, by a person qualified in fire
12 protection engineering, that the facility meets all of the
13 conditions and standards established by the Secretary for
14 such waiver. The conditions and standards established by
15 thdie Secretary under the preceding sentence shall insure lint
16 any facility with respect to which a waiver from the auto-
17 matic sprinkler requirement is granted will be otherwise
18 protected from fire, and that such waiver will not adversely

19 affect the health and safety of the paticints. Such conditions
20 and standards shall be established by the Secretary within
21 six minonts of the date of enactment of the Act.".
22 SEC. 2. (a) 1902 (a) (28) of the Social Security Act
23 is amended by inserting after "requirements contained in
24 section 1861 (j)," the following: "including specifically a
25 provision that any such facility (and any other nursing fa-






40


3
1 cility receiving such payments) Im-iit satisfy all of the re-
2. q(lirclIents with respect to automatic sprinkler systems
3 which are imposed by or under paragraph (13) and the last
4 paragraph of that section;".
5 (b) Clause (3) iln lie first sniIt(ci( of section 1905 (c)

6 of such Act is a.niaieded by the striking out "nicets such
7 standaanrdb" aid inls(,rting in liel tlire'of "nimets tlihe same
8 requiremnieits with respect to automatic sprinkler systems as
9 those which are imposed upon skilled nursing facilities by
10 section 1902 (a) (28), and meets such other standards".
11 SEC. 3. (a) In order to assist long-term care facilities
12 in protecting the lhealtlh and safety of their patients and
13 residents in a manner which complies with the applicable
14 requirements of Federal law, the Secretary of Health, Edu-
15 cation, and Welfare (hereinafter referred to as the "Secre-

16 tary") is authorized to make loans to such facilities as pro-
17 vided in this section for the construction or purchase and

18 installation of autoniatic sprinkler systenis.
19 (b) A loan under this section may be made only to an
20 eligible facility (as defned in subsection (c)), and only for
21 the purpose of assisting suchli facility in constructing or pur-
22 clhasing and installing an automatic sprinkler system which

23 complies witli the requirements imposed by or under para-
24 gra)ph (13) of section 1R61 (j) of the Social Security Act
25 (and the last paragraph of such section), or the requirements






41


4
1 cf .ecii.n i, 1 2 ((a) (2S) or I9)(3('(c) (3)) i sucl Ac(, a;4

? iaay Ih bv i upli.able. An i ],'n ,i Ia>I s.,lll- .

(I) le' i s.uI) ainiieiiit S ias may l' rebieonaIlhC aiid
I nei'cessirv, ill addilio Iii,,I: %" ller lfnds ra ailahllc l41

5 lt flir i ility, li (p i .m (6i syslein. as deh'rnile'd i, a,'co'rdalcN witl i re'gilitim,,i

7 ipre'serilird l y tilt' Se'crelarv;
S (2) 'a'r interest at a rat li it exce'eding (1 p1r

9) ('iituni i er ai] n llullll i ,hI out(stallding i alance;

In (3) hiave a mliniritv. not to ('xceedl twenty yein N,
11 as detcrnined Ib Ihi Serc'tarv il tlie baisi.,s (if tilei fa-

12 eilitv's ability to rep-ay aindl ti lprojecled useful life of

13 tlhe sitrnuture r strulctures involved; aind
14 (4) be. siiljec't to sucih additional tennis, conditions,

15 aind provisions as tie Sereltary m ay impose in order to
li assure that the objectives of this sectiil iand thie pur-
1 poses o)' tlhe medicare and medicaid programs will be

1s effectivelyv carried out.

19 Each application for a loan under this' section shall be ae-
20 comnpanied hy 'ertifiatin to t lie Secre lary lvthat tliet installa-
2.1 tion will bei mvde ill a(corda;iie with the standards estab-

22 lis.hed Iy thie Natiial Fire i'reii As\oiatiilon (Numlber
23 13, 1,975 edilioin). N, such a)p]lic;iton slill 1le approved

2-4 unless such certification is made to the Seeretarv.
25 (C) As used in l this section thle term' "eligible facility"






42


5
1 -means a skilled nursing facility, nursing home, or intermiedi-
2 ate care facility withind the inwaning of title XVIII or XIX
Sof tOle Social Security Act) which liIs been certified for par-
4 ticipation ii lthe medicare pro g'raml under such title XVIII
5 (or in a iiedicadl i-sisfiiicc proqgran iiidcr ;i Saizate phli

Sa approved uiiiider siucIi title XIX, or \'hi]li is seeking or pro-

7 p'mes to seek suci' certification.

S (d) Tlihere are authorized to be appropriated sucli suins
9 as may be iect'es-airy for purposes of this section. Amounts

10 "o apl)proriated shall placed in and constitute a revolving
11 fund which shall be available to the Secretary for use in

12 carrying out this section.
13 SEC. 4. The amendments made by the first two sections
14 of this Act-,

15 (1) shall apply with respect to all facilities onl wlichl
16 construction is comme)inced oil o1. after the first day of
17 the sixtll mouth followinlg the monthly in which this Act
18 is enacted; and ?

19 (2) slall apply with respect to all facilities, already
20 inl existel(nce (or on w]ich construction is eolumtenced
21 before the first day of such sixth month) (effective from
22 and after the first day of tlie eighteenth month follow ing
2'3 the monthly in which this Act is enacted.






43


94-n[ CONGIUK.SS
21) S H. R. 15576




IN T1 1 ]1101 ', OFi IE'PRES, NIATI ES
SK- KM IU.II 15; 1976
Mr. IIi.:.xz introdiuiecd tie followillg hill; wilicl w,, rrc e, jointly (to tlhe
CoimitItet s fi n llWayi and l .Mi.ci.s. tI.,'.i.-it 1 :i1lt (l Foreign (Coiirmerce, and
Veterains' A fairs




A BILL
To require aitoinimtic sprinkIi-r vsyslmes in i all skilled nur'..sinig
fa.ilities and iliferiiediat .meire facilities 'is d 'collditiol, of
certificatioii niuder theli iiedie< i', nI'dicaid, and Vetetrais'
Adniiiiistfritio, priigr i i. 'i, d to a htlirlze h ,.1E 1 1d gr;,ii( s
to n.sist s 'ini f;i systems.
1 Be it enacted by the Senate and Hou.sc of Icit'cspef a-
2 tit's of the Unitded States of America in Congres.s assembled,
3 Thiat, (a) notwitliNstanding iny other provision of law (ex-
4 cept subsection (1h) of thiis section), no nursing failility slill
5 be certified as a skilled nursing facility for purpose. of p!r-
6 ticipation in theli hospital insurance p'rogrami under title
7 XVIII of the Social Sevurity Act. no nursing facility m'






44


2
1 ilnterllmediate care faicilily shall he certified or a approvedd for

2. plrpses 1 '(f parli'ilpliotn in ;a lildical assistaIlct' e prolgral
3 under a Slate planil approved iiinder lille XIX of smul Act,

4 and no nursing facility or intermediate care facility shall he

5 approved for partlicipation in any program under the juris-
6 diction of the Vetcrans' Adniinistrantion, for any period be-
7 glinning onl or after the expiration of two years from the date

8 of thle e,,actment of this Act, unless such facility hlias a
9 sprinkler, system which is determined by the Secretary of

10 heallill, Educatiion, and Welfare, hereinafter in this Act
11 referred to as 11i "Secretary", or the Administrator of
12 Veteranis' Affairs (as tlie case may lc) to satisfy the appli-
1:1 ca!le reiuireceits of stanIdard numbered 13 of tlhe 1975
14 edition of the National Fire Protection Association (amid
1." siclI later editions as tlit( Secretary miay determinee.
16 (b) Tlie Secretary miny waive this requiremnent only ii,
17 case where hbelausse the size or, nature of the structure of thie

is skilled nursing facility or intermediate care facility, the ill-

19 stallation of a complete sprinkler system would constitute an
20 unreasonable hardship. In such cases, thle Secretary sliall
21 require such compens:Matory fire protection features as lie
22 deems appropriate for the size and nature of the structure.

23 1SEC. 2. (a) For thle purpose of assisting skilled nursing
21 annd intermediate care facilities in protecting the health and
25 safety of their patients and in nlmecting the requirements of




45


3
1 Federal law relating thereto, the Secretary is authorized,
2 in the manner provided in section 1620 of the Public Health
3 Service Act and subject to the conditions and requirements
4 of that section except to the extent inconsistent with the
5 succeeding provisions of this section, to make loans to such
( facilities to assist them in financing part or all of the cost
7 of purchasing and installing automatic sprinkler systems.
8 (b) A loan under this section may be made only to an
9 eligible skilled nursing or intermediate care facility (as de-
10 fined in subsection (c)), and only for the purpose of assisting
11 such facility in purchasing and installing an automatic
12 sprinkler system which satisfies the applicable requirements
13 of standard numbered 13 of die 1975 edition of the National
14 Fire Protection Association (and such later editions as the

15 Secretary may determine). Any such loan shall-
16 (1) be in such amount as may be reasonable and
17 necessary, in addition to any other funds available to the
18 facility, to purchase and install such system, as deter-

19 mined in accordance with regulations prescribed by the
20 Secretary;
21 (2) bear interest at a rate not more than 1 per
22 centum higher than the average outstanding discount rate
23 (at the time the loan is made) of the Federal Reserve
24 bank for the district in which the facility involved is
25 located;






46


4
1 (3) have a maturity of not more Ilhai twenty years;
2" and
3 (4) be subject to such additional terms, conditions,
4 and provisions as the Secretary may impose iin order to
5 assure that tlhec objectives of this section will be effective-
6 ly carried out.
7 Each application for a lhan under this section shall not be
8 subject to approval under section 1.604 of the Public Inellh
9 Service Act. No such application shall be approved unless tlhe
10 Secretary finds that (A) the structure involved hiis a
11 projected useful life as a skilled nursing care facility or inter-
12 mediate care facility of at least ten years and is otherwise
13 qualified for certification under title XYVIII or XIX of the
14 Social Security Act or approved for participation in any pro-
15 grain under the jurisdiction of thle Veterans' Administration.
16 (c) As used in this section, the term "eligible skilled
17 nursing or intermediate care facility" ineans a skilled nursing
18 facility within the meaning of section 1861 (j) of the Social

19 Security Act, or an intermediate care facility within the
20 meaning of section 1905 (c) of such Act, whijh.-
21 (1) hlias been certified for participation inl the mcedi-
22 care program under title XVIII of such Act or in a
23 medical assistance program under a State plan approved
2-4 uider title XIX of such Act, or is seeking or proposing to
25 seek such certification;




47


5;?

1 (2) does not have in operation a complete auto-
2 matic sprinkler system and is unable (as determined by
3 the Secretary) to obtain from private sources all of the
4 financing needed to purchase and install such a system.
5 (d) There are authorized to be appropriated such sums
6 as may be necessary for purposes of this section. Amounts so
7 appropriated shall be placed in and constitute a revolving
8 fund which shall be available to the Secretary for Luse ill
9 carrying out this section.
10 SEC. 3. (a) In the case of an eligible skilled nursing or

11 intermediate care facility (as defined in section 2 (c)) and:
2 (1) serves a primarily rural, medically underserved,
13 or low-income population,
14 (2) at least 85 per Centunm of the patients or r'si-
15 dents of which are recipients of medical assistance under
16 a State plan approved under title XIX of the Social

17 Security Act,
18 (3) is unable to underwrite the costs of purchasing

19 and installing an automatic sprinkler system through its
20 own financial resources, including its endowment if any,
21 and
22 (4) is either a publicly owned and operated facility
23 or a facility described in section 501 (c) (3) or (4) (of
24 the Internal Revenue Code of 1954 which is exenipt
25.3 from income taxes under section 501 (a) of such Code.





48


6

1 thle Secretary is authorized, in their manner provided in see-

2 tion 1625 of the Public Health Service Act and subject to
3 the conditions and requirements of such section except to the
4 extent inconsistent with the provisions of this section, fo make
5 a grant or grants to suh facility to enable it to purchase and
6 install an automatic sprinkler system satisfying the applicable
7 requirements of standard numbered 13 of the 1975 edition

8 of the National Fire Protection Association (or such later
9 editions as the Secretary may prescribe).

10 (b) Grants under this section-
11 (1) may be made in lieu of or in supplementation
12 of such loans; and

13 (2) shall be subject to such termnis and conditions as
14 the Secretary may prescribe to assure that the objectives
15 of this section are effectively carried out.

16 (c) There are authorized to be appropriated such sums
17 as may be necessary to enable the Secretary to carry out this

18 section.

19 SEC. 4. No later than ninety days after the date of the
20 enactment of this Act, the Secretary shall prescribe and pub-

21 lish such regulations as may be necessary or appropriate to
22 carry out this section.
23 SEC. 5. Except as otherwise provided in the first section
24 of this Act, the provisions of this Act shall take effect on the
25 date of its enactment.







49


Appendix III


COMPTROLLER GENERAL'S FEDERAL FIRE SAFETY REQUIREMENTS DO
REPORT TO THE CONGRESS NOT INSURE LIFE SAFETY IN NURSING
June 3, 1976 HOME FIRES
Social and Rehabilitation Service
Department of Health, Education, and
Welfare


DIGEST

As a result of two nursing facility fires
that killed 31 people during early 1976, the
Chairman, Subcommittee on Health and Long-
Term Care, House Select Committee on Aging,
asked GAO to investigate reasons for the
severity of the fires and to suggest possible
actions to avoid similar situations.


According to reports of investigations:

--Multiple deaths occurred in these and sev-
eral fires in prior years even though the
buildings were of fire resistive construc-
tion and were in substantial compliance
with the Federal fire safety requirements.


--Deaths were caused by smoke and products
of combustion rather than by flames be-
cause the flames were confined to the
rooms of origin.

--Neither facility was fully protected with
an automatic sprinkler system designed to
activate an alarm and begin fighting the
fire immediately.

--Although local fire departments responded
promptly to both alarms, the fire depart-
ments were unable to prevent the deaths
which occurred.

--Facility employees tried to evacuate resi-
dents and extinguish the fires, but in
neither case were they successful in pre-
venting death or extinguishing the fires.


--Although a short period of time elapsed
from the identification of the fires to


MWD-76-136







50


the arrival of the fire departments, the
fires generated intense heat, resulting
in considerable fire damage to the Luoms
in which the fires originated.


--Experts said automatic sprinklers would
have prevented the deaths in these homes.


Studies by congressional committees, a fire
safety engineering firm, a special investi-
gative committee, and others have pointed
out the need for and the benefits of auto-
matic sprinkler systems in nursing facili-
ties.

GAO determined that the cost of sprinkler
system installations ranged from $393 to
$625 a bed. The amortized cost of $625
over a 20-year period with a 9-1/4 percent
interest rate is $5.57 a bed each month,
or about 19f a bed each day.


With the installation of a sprinkler sys-
tem, savings on nursing facility fire
insurance premiums are possible on both
the building and its contents. Through
reimbursement for depreciation and inter-
est, Medicare and Medicaid will pa-, for
part of the cost of sprinkler system in-
stallation.

The program which authorized the Department
of Housing and Urban Development to provide
Federal loan insurance for the installation
of fire safety equipment has not been util-
ized. GAO believes that excessive process-
ing time by HE4 and the Department of Hous-
ing and Urban Development procedures, which
prohibit loan insurance after work has begun,
contribute to the problems facing nursing
facilities applying for loan insurance.


GAO recommends that the Secretary of HEW
minimize the problem of excessive processing
time by establishing procedures which make
better use of existing survey and certifica-
tion documents.










GAO recommends that the Secretary of Housing
and Urban Development

--establish regulations to permit fire safety
equipment loan insurance after work has
begun

--publicize the availability of the fire
safety equipment loan insurance program by
revising the nursing home brochure dealing
with nursing home mortgage insurance.


Because congressional hearings were sched-
uled, the chairman's office requested that
GAO not delay the report to get formal com-
ments from HEW and the Department of Housing
and Urban Development. Informal comments
from agency officials were considered where
appropriate in this report. The National
Fire Protection Association and the National
Fire Prevention and Control Administration
of the Department of Commerce agreed with
GAO's recommendations to the Congress.


RECOMMENDATIONS TO THE CONGRESS

GAO believes that a strong case can be made
for requiring that all nursing facilities
be fully protected with automatic sprinkler
systems. Therefore, in line with previous
recommendations of congressional committees,
we recommend that the Congress enact legis-
lation which will require that all nursing
facilities be fully protected with an auto-
matic sprinkler system. The Congress should
require HEW to establish rigid standards
which must be met by nursing facilities re-
questing waiver from the automatic sprinkler
requirement.




UNIVERSITY OF FLORIDA
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