CMS publishes new Life Safety Code rule, effective immediately

CMS issued a new S&C letter on May 6, 2016 alerting healthcare providers, including long term care facilities, that new Life Safety Code (LSC) requirements have been adopted. These fire safety requirements are updated and distributed every three years by the National Fire Protection Association (NFPA). The final rule, “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities,” advises providers that the 2012 edition of the LSC, NFPA 101 and the 2012 edition of the Health Care Facilities Code, NFPA have been adopted. The 2012 edition of the Health Care Facilities Code has some specific exceptions outlined within the rule.

This rule updates the fire protection guidelines for health care facilities while providing facilities with the ability to create a more “home-like” environment for their residents. Some of the changes – which are allowed under specific sets of requirements for each section – include:

  • Ability to place fixed furniture in corridors (as long as they meet ADA requirements)
  • Ability to have wheeled equipment that is in use, medical emergency equipment not in use, and patient life and transportation equipment to be kept in corridors for more timely patient care
  • Cooking facilities may open to the corridor if certain conditions are met
  • Combustible décor is allowed so long as:
    • It is flame-retardant or treated with an approved fire-retardant coating that is list and labeled and meets fire test standards
    • Does not exceed set-out specific percentages of the wall/ceiling/door
    • Is not in a room that is not protected by an approved automatic sprinkler system
  • Direct-vent gas fireplaces are allowed in smoke compartments that have a 1-hour fire wall rating, but may not be placed in resident rooms. Solid fuel-burning fireplaces are permitted but may also not be used in resident rooms, and must be separated from sleeping rooms by construction of no less than 1-hour fire resistance wall rating.

Some highlights of other changes include:

  • Alcohol-based hand rub (ABHR) dispenser types have been expanded to allow both aerosol and gel ABHRs, which can help improve hand hygiene
  • Door locking, under certain circumstances
  • A requirement that a building must be evacuated or institute an approved fire watch when its sprinkler system has been out of service for more than 10 hours in a 24-hour period until the system is returned to service

These updates have been adopted to both increase the safety of residents while allowing flexibility in design and reducing the “institutional” nature of nursing homes.

View the full final rule and read CMS S&C letter “Notification of Final Rule Published: Adoption of 2012 Life Safety and Health Care Facilities Code,” (Ref: S&C: 16-22-LSC) for specific details on these and other changes.

Do you have a LIfe Safety Code or other environmental concern? Contact CMS Compliance Group today to learn about how our consultants can help, or learn more about our Environmental Consulting services for nursing homes.


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