Updated 5/18/21
Below are responses to questions from the about the CDS/CMHC Mitigation Plan Requirement Webinar
Q: For the regularly scheduled Fire Marshall visit, does the agency need to contact the Fire Marshall to initiate the visit?
A: No, for regular certificate renewal fire inspections when the previous inspection had NO violations, BALC will enter them into the OSFM portal prior to your program expiring. However, you may always monitor your own compliance and contact BALC to ensure your fire inspections have been requested.
Q: After a OSFM visit that fails only for a missing report (Sprinkler test, Alarm test, etc.) Can we send the needed report somewhere or will it require another OSFM visit to get clearance?
A: If the violation is test documentation, you may send these directly to the OSFM inspector. Many times this will be coordinated during the visit between the agency and the inspector. If the documentation was the only violation, another physical on-site reinspection may not be required to clear the site, but a reinspection request/referral is still required for the cleared report to be issued.
Q: When would be the last applicable fire marshal passed report that's considered in compliance to start of 4 cycle for CDS?
A: Any passed report after 9/1/2020. If the CDS site was in the 1 year compliance at the time of the policy change (eff. Sept 1, 2021) then it is due 4 years from the passed date.
Q: Do individually controlled CILA sites require OSFM inspections?
A: Individually Controlled CILA sites do not require OSFM inspections, but Host Family settings of any kind do require a OSFM inspection.
Q: Open failed reports prior to June 1st for which we submit a Target Date of correction, do we also submit the Fire Inspection request form by the date noted, or are you automatically using the date to submit to the OSFM for reinspection?
A: You must submit a Fire Inspection request form to initiate all re-inspections, including those that you included with target Dates.
Q: What is the time frame to fix an issue? How long do we have?
A: BALC has not set a specific timeframe for when violations must be corrected. At this point as long as you are actively correcting the issue, making progress and continue to communicate with BALC, no negative action will be taken.
Q: We failed an inspection, submitted a mitigation plan and passed the reinspection with the fire marshal. Will we need any follow up on June 1st?
A: No, the only required actions are for failures prior to June 1st that are still uncorrected, and new failures after June 1st.
Q: For agencies that have multiple certifications - ie CDS, CILA and CMHC, if there is a repeat violation, will the penalties, to all DHS certifications and licenses?
A: The penalties will apply only to the program that incurred the repeat violations
Q: For an existing site that has a large construction project, at what point do we need to request re-inspection?
A: Only request reinspection what when you have completed all aspects of the large construction and you believe all OSFM requirements are met.
Q: Can I request a reinspection if most of the violations are fixed, but not all of them?
A: No, only request a reinspection when all violations for a specific site have been corrected. If the OSFM returns and issues a repeat violation, you will be subject to the penalties process.
Q: In some cases, we see a delay between the time the re-inspection form is sent, and when the OSFM contacts the provider for the re-inspection. Who should we contact, if this delay exceeds a couple/few months?
A: OSFM delays are very common and regionally dependent. BALC has no access or influence over the inspector's schedule. If it has been over two months, you may contact BALC and we can check to ensure it is at least on an inspector's list. Do not contact the OSFM directly.
Q: Are the mitigation plans for CDS and CMHC any different from the ones we submitted in September for CILA? Or similar format?
A: The Mitigation Plan excel spreadsheet format is identical for all programs.
Q: Are there any special considerations for adding a new CILA or CDS at this time?
A: No, the Mitigation Plan requirement is only for approved and active sites, not new sites. New sites not yet approved or occupied will be approved whenever you are able to correct any violations and the site is cleared by the OSFM
Q: What if we decide work is too expensive so we move?
A: Continued licensure and certification is dependent on being in compliance with the OSFM. If you decide you are not able to come into OSFM compliance and are closing the site, contact BALC and we will remove the site from your license and our system.
Q: On the sample mitigation form it asks for number of individuals -- if this is an office setting, what number is included here? Patients seen daily? Number of staff routinely onsite?
A: In an office or CDS setting, you may provide the typical number of daily occupants, to include patients, supported individuals, and/or staff
Q: During a fire marshal inspection, what is the main things that fire marshal inspecting for?
A: BALC is not an authority on the life safety code and the OSFM's inspection standard and BALC does not provide specific fire code guidance in order to avoid contradicting an inspector's determination. We can however, direct you to OSFM resources available to the public. Follow this link for guidance on the OSFM technical services division website.
