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Nursing Home NFPA Life Safety Code (LSC) Waivers

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CMS has found that several requirements of the National Fire Protection Association (NFPA) 2000 edition cause an undue burden on nursing facilities and is making available waivers if satisfactory alternatives are in place. As per its August 30, 2012 S&C letter, “2000 Edition National Fire Protection Association (NFPA) 101 Life Safety Code (LSC) Waivers” (Ref: S&C 13-58-LSC), Individual waiver applications do not need to be submitted, but providers must have written documentation that the waiver will be used and the survey team must be notified at the entrance conference of the facility’s intent to use a waiver.

In a March 9, 2012 CMS Memorandum, categorical waivers were also permitted, but required that each waiver was submitted and approved before a survey took place. These waivers will now follow the waiver process listed in this letter.

The following categorical waivers will be allowed:

  1. Medical Gas Master Alarms – A waiver will be permitted to allow a centralized computer system to substitute for one of the Category 1 medical gas master alarms, provided that compliance with all other applicable 1999 NFPA medical gas master provisions and section 5.1.9.4 of the 2012 NFPA 99 are met.
  2. Openings in Exit Enclosures – A waiver will be permitted to allow existing openings in exit enclosures to mechanical equipment spaces that are protected by fire-rated door assemblies. The provider must be in compliance with all of the other applicable 2000 LSC exit provisions in addition to section 7.1.3.2.1(9)(c) of the 2012 LSC.
  3. Emergency Generators and Standby Power Systems – A waiver that allows for a reduction in the annual diesel-powered generator exercise requirement will be lowered from two continuous hours to one hour and thirty minutes will be permitted. To qualify, the provider must be in compliance with the operational inspection and testing provisions of 1999 NFPA 110 and with section 8.4.3.2 of the 2010 NFPA 110.
  4. Doors – A waiver to allow door locking arrangements where there is clinical justification, security risk by residents or specialized safety protective measures will be allowed as long as the provider meets all the requirements for 2000 LSC door provisions and 2012 LSC sections 18/19.2.2.2.2 – 10/19.2.2.2.6.
  5. Suites – A waiver that will accommodate the use of suites will be allowed if requirements are met based on the new S&C letter, as well as if the provider is in compliance with all other applicable 2000 LSC provisions and sections 18/192.5.7 of the 2012 LSC.
  6. Extinguishing Requirements – A waiver will be permitted that allows for the reduction in the testing frequencies of sprinkler system vane-type and pressure-switch type water flow alarm devices will be made semi-annual and electric motor-driven pump assemblies will be required monthly. To qualify, the provider must be in compliance with all the other testing provisions of 1998 NFPA 25 and with the 2011 NFPA 25 sections 5.3 and 8.3.
  7. Clean Waste & Patient Record Recycling Containers – A waiver allowing an increase in the size of containers used for recycling clean waste and patient records that are set to be destroyed can be up to 96 gallons. The provider must also comply with the requirements of section 18/19.7.5.7.2 of the 2012 LSC.

Earlier this year, CMS mandated that the installation of sprinklers throughout the entire nursing facility would be required by August 13, 2013. As August came and went, there was a discussion about waivers being issued for facilities that had not yet completed this requirement, but CMS noted that a deficiency would be cited if a fully automatic sprinkler system was not in place by the deadline that month. No further information on a waiver for having a fully automated sprinkler system has been announced yet.

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