Life Safety Code Waiver Requests
of DQA 11-015 (PDF, 49 KB)
Life Safety Code Waiver Requests
The purpose of this memorandum is to clarify how Life Safety Code NFPA
101 (LSC) waiver requests should be developed by Medicare and Medicaid
participating health care providers. Overall, the number of denied requests
has resulted in a significant increase in work for all parties involved.
The Wisconsin Department of Health Services (DHS) is attempting to
address any misunderstandings by proactively notifying all providers that
are regulated by the Life Safety Code.
The need for a waiver occurs for a variety of reasons including when a
provider is unable to correct a deficiency and requests an exception in lieu
of strict compliance.
After receiving a DHS Statement of Deficiencies (SOD),for instance, the
provider requests a waiver within their Plan of Correction (POC). DHS will
make a recommendation. Favorable recommendations will be forwarded to the
Centers for Medicare and Medicaid Services (CMS) Chicago Regional Office for
Waivers to the LSC are permissible if:
- The waiver does not adversely affect patient / resident health and
- strict compliance would impose an unreasonable hardship on the
Approval is not automatic yet is favorable if the following justification
- FLOOR PLAN (recommended)
Provider indicates the location of the LSC deficiency on a simplified
floor plan showing the floor, wing, and room names affected.
- COST ESTIMATE (required)
Provider analyzes a range of cost alternatives to correct the
deficiency, then forwards a reasonable cost estimate from a reputable
third party, that is two years or less in age. Costs can include
relocation of residents / patients during construction and disruption of
services (IE food service). Provider must ensure that the scope of work is
identified within the cost estimate.
- FINANCIAL HARDSHIP (required)
Provider explains how strict compliance would pose a financial hardship
to the facility's viability:
- simplified fiscal year 'profit & loss" statement,
- availability of financing,
- payback period if deficiency is corrected, or
- remaining useful life of the building.
- PATIENT/RESIDENT HEALTH & SAFETY (required)
Provider evidence that the LSC deficiency does not pose a hazard to
occupants by detailing compensating safeguards that exceed code-minimum,
- additional staffing, fire training, safety rounds, or fire watches,
- certified training or competency skill documentation of physical plant
- additional detectors, fire extinguishers, or fire extinguisher
- additional means of notifying emergency responders or staff in
- additional inspections (building, equipment, or fire department)
- additional fire barriers, smoke compartments, or exits,
- additional preventative maintenance or housekeeping that minimize
- fire protection professional who develops a plan of action,
- extraordinary local fire department response (e.g. response time,
equipment available, number of personnel that respond, and
distance to the fire station).
This memorandum is motivated by the mutual concern of the Department and
providers for compliance with the requirements, and to maximize safety for
all occupants. All ongoing LSC deficiencies are recited at each survey, and
no waiver should be assumed to be absolute. CMS reserves the right to review
or revoke any and all waivers at any time. Providing the above-listed items
does not guarantee an approved waiver. Failure to follow the conditions
agreed to within a waiver request may result in waiver revocation,
retroactive physical plant impacts or CMS enforcement actions.
Please direct all questions about the content of this memo to David
Soens, Director, Office of Plan Review and Inspection at (608) 266-9675.
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Last Updated: September 30, 2011