CMS May Update Facilities' Life Safety Code

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  • In CMS
  • April 24, 2014
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Proposed changes to the National Fire Protection Association’s (NFPA) Life Safety Code (LSC) will bring it more in line with the insurance industry’s, the Centers for Medicare & Medicaid Services (CMS) says. It might reduce the burden on facilities and staff, too, the agency said. The deadline to submit comments is June 16, 2014.
The new rules, based on the 2012 editions of NFPA’s LSC and Health Care Facilities Codes (HCFC), would revamp rules adopted in 2000. The HCFC contains more detailed provisions specific to healthcare and ambulatory care facilities. CMS maintains adoption of this code would provide minimum requirements for the installation, inspection, testing, maintenance, performance, and safe practices of healthcare facility materials, equipment,  and appliances.
The new edition of the LSC would apply to hospitals, long-term care (LTC) facilities, critical access hospitals (CAHs), Programs for All Inclusive Care for the Elderly (PACE), religious non-medical healthcare institutions (RNHCIs), hospice inpatient facilities, ambulatory surgical centers (ASCs), and intermediate care facilities for individuals with intellectual disabilities (ICF-IIDs).
Adoption of the new LSC and HCFC (applicable to hospitals, LTC facilities, CAHs, Hospice inpatient facilities, PACE, and RNHCIs) would be required to:

  • Allow facilities to increase suite sizes;
  • Have all high-rise buildings over 75 feet be fully sprinklered within 12 years;
  • Allow controlled access doors to prevent wandering patients;
  • Address issues of alcohol-based hand rub dispensers in corridors and patient rooms;
  • Impose a fire watch (the assignment of a person or persons to an area for the express purpose of notifying appropriate people during an emergency) or building evacuation if a sprinkler system is out of service for more than 4 hours; and
  • Have smoke control in anesthetizing locations.

The key changes for ASCs would require:

  • Interior non-bearing walls to have a minimum 2 hour fire resistance rating and be constructed with fire retardant treated wood;
  • All doors to hazardous areas to be self-closing or automatic closing;
  • Addressing the issue of placing alcohol-based hand rub dispensers in corridors;
  • A fire watch or building evacuation if the sprinkler system is out of service for more than 4 hours; and
  • Smoke control in anesthetizing locations.

The major changes for ICF-IIDs would require:

  • An expanded sprinkler system, to include habitable areas, closets, roofed porches, balconies, and decks in new facilities;
  • All attics to be sprinklered if they are used for living purposes, storage or housing of fuel fired equipment; if they are not used for these purposes, attics may have heat detection systems instead;
  • All designated means of escape be free from obstruction;
  • New facilities to have smoke alarms installed on all levels;
  • Access-controlled egress doors to be equipped with electrical lock hardware to prevent residents from wandering away;
  • Hazardous areas to be separated from other parts of the building by smoke partitions; and
  • Existing facilities to include certain fire alarm features when they choose to update their fire alarm systems.


Brad Ericson
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Brad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor. He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

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