CMS Adopts Life Safety Code
PDF Version of BQA 03-006 (PDF,
Date: April 3, 2003 -- BQA Memo 03-006
Nursing Homes NH - 03, Facilities for the Developmentally Disabled
Hospitals HOSP - 04,
- 04, End Stage Renal
Dialysis Units ESRD 01, Ambulatory
Surgical Centers ASC 01
FROM: Jan Eakins, Chief, Provider Regulation and
Quality Improvement Section
cc: Susan Schroeder, Director, Bureau of Quality Assurance
The Centers for Medicare and Medicaid Services (CMS) has formally
adopted, by reference, the 2000 edition of the Life Safety Code (LSC) of
the National Fire Protection Association (NFPA). Adoption by reference
occurred January 10, 2003 in the Federal Register with an effective
date of March 11, 2003. All health care facilities referenced in
the rule require compliance on September 11, 2003. Copies of the
Federal Register document detailing these requirements can be obtained at:
(PDF, 96 KB).
CMS states that while all health care facilities will be affected, most
will be affected minimally. Each new edition of the Life Safety Code (LSC)
builds on the prior editions. Most health care providers and advocates
complained that facilities are exposed to additional work and expense
without gain in fire safety by continuing to abide by multiple editions of
the LSC. Multiple editions of the LSC also has caused confusion, as well
as additional burden to the health care industry in requesting waivers,
changing renovations, and complicating surveys. By adopting the 2000
edition of the LSC, CMS will eliminate confusion as to which edition a
health care facility must follow. The use of a single edition of the code
will also contribute to lowering the cost of complying with the
requirements for testing and maintenance of fire protection systems.
Health care facilities NOT affected by this final rule are:
- Facilities not participating in the Medicare/Medicaid programs, for
- residential hospice programs,
- private-pay facilities.
- End-Stage Renal Disease (ESRD) facilities.
The final rule removes ALL prior editions of the LSC,
specifically the 1967, 1973, 1981 and 1985 editions of NFPA 101, from the
Existing facilities will fall under Chapter 19 "Existing Health
Care Occupancies" of the 2000 edition of NFPA 101.
CMS identified six LSC requirements critical to the safety of
beneficiaries summarized as follows for existing facilities:
1) Roller latches (188.8.131.52.2) – Requires replacement of
corridor door roller latches with standard latching hardware. There is a
3-year phase-in for compliance beginning March 11, 2003 and ending March
2) Emergency Lighting (19.2.9) – Requires providing emergency
lighting for 1 ˝ hours, to be phased in over a 3-year period beginning
March 11, 2003 and ending March 13, 2006.
3) Protection of Vertical Openings (19.3.1) – Vertical
openings required to be enclosed, with 1-hour construction, shall be
corrected by September 11, 2003.
4) Emergency Forces Notification (184.108.40.206.2) – Requires the
fire alarm system to provide automatic notification of a fire to emergency
forces without any delay to be corrected by September 11, 2003.
5) Corridors (220.127.116.11) – Requires all areas of non-sprinklered
buildings to be separated from the corridor with 1/2 hour rated walls to
be corrected by September 11, 2003.
6) Upholstered Furniture (18.104.22.168 and 22.214.171.124) – Requires
rooms with patient/resident owned furniture to have a smoke detector
installed by September 11, 2003.
Additional items may affect a facility that CMS did not identify
within this list. See the ‘Resource’ section of this memo below for
additional information. Renovations, alterations, modernizations, or
repairs shall not reduce the life safety below the level that
WAIVER / EQUIVALENCY REQUESTS
CMS retains the authority to waiver provisions of the 2000 edition of
the LSC, on a case-by-case basis, and thereby reduce the exposure to
additional costs and burden for those facilities with unique situations
that may justify the application of a waiver or equivalency.
The Department of Health and Family Services (DHFS) Fire Authority, in
coordination with the assigned department engineer, will recommend
approval or denial of a waiver request to CMS. CMS may grant a waiver for
a specific LSC requirement if:
- The waiver will not adversely affect patient and staff health and
- The waiver would impose an unreasonable hardship on the facility to
meet the specific LSC requirement.
DHFS and CMS will not grant a waiver if patient/resident safety is
compromised in any way.
CMS also retained the authority to apply the Fire Safety Evaluation
System (FSES) as an alternative approach to meeting the requirements of
the LSC. The FSES alternative approach is used by qualified individuals
trained and experienced in the proper application and limitations of the
FSES. This approach is not to be used if patient/resident safety is
compromised in any way.
Facilities surveyed annually, nursing homes and intermediate care
facilities for persons with Mental Retardation, are encouraged to make
waiver requests at the time of survey through the Plan of Correction (POC)
process. Requests outside of a survey must specify the code section
petitioned and can be forwarded to:
- Provider Regulation and Quality Improvement Section
Attn: Jan Eakins, Chief
Bureau of Quality Assurance
PO Box 2969
Madison, WI 53701-2969
Copies of the Federal Register document detailing the requirements
outlined in this memorandum can be obtained at: www.dhfs.state.wi.us/
(PDF, 96 KB).
Facilities are encouraged to be cognizant of the regulations affecting
their facilities. Copies of the 2000 edition of the LSC are available from
NFPA in both electronic and bound versions. NFPA can be contacted at: 1-800-344-3555
or at www.nfpacatalog.org (exit
The Bureau participates in annual training events open to providers and
designers to provide a pro-active approach to aid consistent health care
regulation. The Bureau frequently participates in training with the
- Wisconsin Building Code Refresher or Building Code Intensive
sponsored by University of Wisconsin – Department of Engineering
Professional Development. Details are available at http://epdweb.engr.wisc.edu
(exit DHFS) or by calling (800) 462-0876.
- Wisconsin Healthcare Engineering Association (WHEA) sponsors an
annual conference specific for health care facilities including
physical plant and regulatory sessions. Details available at www.whea.com
(exit DHFS) or by calling (608) 524-5054.
Health care facilities are encouraged to seek private sector design
professionals if physical plant impacts, financial estimates, or risk
assessments are sought regarding their specific facility in relation to
the 2000 edition of the Life Safety Code.
The Department Health and Family Services (DHFS) anticipates enforcing
the 2000 edition of the LSC starting with surveys taking place on or after
September 11, 2003. CMS is currently authoring and organizing its
guidance to state survey agencies. The Department’s LSC surveyors will
participate in CMS sponsored LSC training in the near future. Additional
clarification of facility impacts, waivers, and resources may become
available at a later time.
Fire reporting forms are available at http://www.dhs.wisconsin.gov/forms1/F6/F62500.pdf
(PDF, 23 KB).
All incidents of fire in a hospital, nursing home or facility for the
developmentally disabled are required to be reported to the Department
within 72 hours. Reports can be faxed to the Fire Authority at (608)
Questions or comments regarding the CMS adoption process or rule
changes can be forwarded to CMS at: http://cms.hhs.gov
(exit DHFS - address updated).
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