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CMS Issues Guidance on Categorical Waivers for Certain Life Safety Code Requirements

by Published On: Sep 20, 2013

The Centers for Medicare and Medicaid Services (CMS) has issued a Survey and Certification Letter identifying several areas of the 2000 edition of the Life Safety Code (LSC) that may result in unreasonable hardship on certified providers/suppliers and for which there are alternative approaches that provide an equal level of protection. 

CMS is making available several categorical waivers to new and existing providers and suppliers subject to the LSC. This memorandum specifies the provisions that are available for waiver, including the conditions for the alternative approaches. 

Individual waiver applications are not required, but providers and suppliers are expected to have written documentation that they have elected to use one or more of the identified waivers and must notify the survey team at the entrance conference for any survey assessing LSC compliance that it has elected the use of a permitted waiver and that it meets the applicable waiver requirements. 

Categorical waivers will not be cited as deficiencies and do require Regional Office approval.

The Details: 2000 Edition National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) Waivers

This letter identifies several areas of the 2000 edition of the Life Safety Code (LSC) determined by the Centers for Medicare & Medicaid Services (CMS) to potentially result in unreasonable hardship on certified providers/suppliers and for which there are alternative approaches that provide an equal level of protection, and describes categorical waivers now available to providers and suppliers subject to the LSC.

  • Under current regulations, CMS may waive specific provisions of the 2000 edition of the LSC which, if rigidly applied, would result in unreasonable hardship upon a provider or supplier, but only if the waiver does not adversely affect the health and safety of patients or residents.

  • CMS determined there are several provision in the 2000 edition of the LSC and 1999 NFPA 99 that may result in unreasonable hardship for providers/suppliers, for which an adequate alternative level of protection may be achieved. CMS is making available several categorical waivers to new and existing providers and suppliers subject to the LSC. 

  • Providers/suppliers wanting to take advantage of one or more of the categorical waivers identified must formally elect to use one or more of the waivers and must document their decision.

  • If a provider/supplier conforms to the requirements identified for each categorical waiver elected, there will be no need to apply specifically to CMS or to wait until being cited for a deficiency to use the waiver.

  • At the entrance conference for any survey assessing LSC compliance, a provider/supplier that has elected to use a categorical waiver must notify the survey team of its’ election, and that it meets the applicable waiver provisions. It is not acceptable to first notify surveyors of a waiver election after a LSC citation has been issued.

  • The survey team will review the provider’s/supplier’s documentation and confirm that all applicable categorical waiver provisions are being met. The waiver(s) elected must be described at Tag K000.

  • Categorical waivers will not be cited as deficiencies nor do they require Regional Office approval. Form CMS-2786 will be marked as “Facility Meets, Based Upon, 3. Waivers.” If the survey team determines the waiver provisions are not being met, a deficiency will be cited. 
Categorical Waivers Available 
  1. Medical Gas Master Alarms

    • The 1999 NFPA 99, sections 4-3.1.2.2(b)(2) requires medical gas master alarms to be located in two separate locations and section 4-3.1.2.2(a)(9) does not allow a centralized computer as a substitute for any medical gas alarm panel.

    • The use of computers to continuously monitor critical signals has increased in health care facilities and the use of computers to monitor medical gas can improve surveillance and shorten response time. As a result, the 1999 NFPA 99 provision required under the 2000 LSC is not only outmoded and unduly burdensome to providers and suppliers, but also arguably less efficient in promoting fire safety.

    • The 2005 edition of NFPA 99, began to permit a centralized computer system to be substituted for one of the master alarms; this policy is continued in section 5.1.9.4 of the 2012 NFPA 99.

    • CMS is permitting a waiver to allow a centralized computer system to substitute for one of the Category 1 medical gas master alarms.The provider/supplier must be in compliance with all other applicable 1999 NFPA medical gas master alarm provisions, as well as with section 5.1.9.4 of the 2012 NFPA 99.

  2. Openings in Exit Enclosure.

    • The 2000 LSC limits opening in exit enclosures (e.g., stairwells) to doors from normally occupied spaces and corridor, and doors for egress from the enclosure, with a few exceptions.

    • Existing health care facilities often have unoccupied mechanical equipment spaces that have an exit access door to an exit enclosure. Providing an alternative exit access to these areas is typically impractical and unduly burdensome with respect to the cost of the reconstruction that would be required.

    • The 2003 LSC, began permitting existing unoccupied openings to mechanical equipment spaces with fire-rated doors to open into exit enclosures, and continuation of this policy is reflected in section 7.1.3.2(9)(c) of the 2012 LSC.

    • CMS is permitting a waiver to allow existing openings in exit enclosures to mechanical equipment spaces that are protected by fire-rated door assemblies. These mechanical equipment spaces must be used only for non-fuel-fired mechanical equipment; must contain no storage of combustible materials; and must be located in sprinklered buildings. The provider/supplier must be in compliance with all other applicable 2000 LSC exit provisions, as well as with section 7.1.3.2.1(9)(c) of the 2012 LSC.

  3. Emergency Generators and Standby Power Systems

    • Section 9.1.3 of the 2000 LSC requires emergency generators and standby power systems to be installed, tested, and maintained in accordance with 1999 NFPA 110, Standard for Emergency and Standby Power Systems. Section 6-4.2.2 of the 1999 NFPA 110 requires diesel-powered generators that do not meet the monthly testing requirements under section 6-4.2 to be run annually with various loads for a total of 2 continuous hours.  

    • Shorter generator run times will reduce undue cost burden and negative environmental impacts. The 2010 NFPA 110 began to allow for total test duration of 1 hour, 30 minutes (1-1/2 continuous hours). 

    • CMS is permitting a waiver to allow for a reduction in the annual diesel-powered generator exercising requirement from 2 continuous hours to 1 hour, 30 minutes (1-1/2 continuous hours). The provider/supplier must be in compliance with all other applicable 1999 NFPA 110 operational inspection and testing provisions, as well as with section 8.4.2.3 of the 2010 NFPA 110.

  4. Doors

    • Section 18/19.2.2.2.2 through 18/19.2.2.2.5 of the 2000 LSC permits door locking arrangements where clinical needs (e.g., psychiatric units, Alzheimer units, dementia units) of the patients require specialized security measures for their safety, provided adequate provisions are made for the rapid removal of occupants by means such as remote control locks or keys carried by staff at all times. 

    • The need for door locking arrangements may extend to other circumstances, such as instances when patients pose a security risk (e.g., in emergency departments) or when a patient requires specialized protective measures for safety (e.g., pediatric units, newborn nurseries). 

    • The 2009 LSC began to allow for door locking arrangements when patients pose a security risk or when patients require specialized protective measures for safety, and continuation of this policy is reflected in the 2012 LSC, in sections 18/19.2.2.2.2 through 18/19.2.2.2.6.

    • CMS is permitting a waiver to allow door locking arrangements where clinical needs justify them, patients pose a security risk, or where patients require specialized protective measures for their safety. The provider/supplier must be in compliance with all other applicable 2000 LSC door provisions, as well as with sections 18/19.2.2.2.2 through 18/19.2.2.2.6 of the 2012 LSC.

    • Section 19.2.2.2.4 of the 2000 LSC permits delayed-egress locks in the means of egress, provided not more than one such device is located in an egress path. However, where the clinical needs (e.g., psychiatric units, Alzheimer units, dementia units) require specialized security measures for safety, or where patients pose a security risk (e.g., emergency departments) or when a patient requires specialized protective measures for safety (e.g., pediatric units, newborn nurseries), more than one delayed egress lock may be required along the path of egress.

    • The 2009 LSC began to allow for more than one delayed-egress lock in an egress path, and continuation of this policy is reflected in sections 18/19.2.2.2.4 of the 2012 LSC, provided that the facility also employs the compensating safety measures specified in those sections which facilitate rapid removal of occupants. 

    • CMS is permitting a waiver to allow more than one delayed-egress lock in the egress path. The provider/supplier must be in compliance with all other applicable 2000 LSC door provisions, as well as sections 18/19.2.2.2.4 of the 2012 LSC.

  5. Suites

    • Sections 18/19.2.5 of the 2000 LSC requires every habitable room to have an exit access door leading directly to an exit access corridor; allows for exit access from a suite to include intervening rooms only under certain circumstances; requires suites of certain size to have two exit access doors remotely located from one another; and limits the size of sleeping room suites to 5,000 ft. The specific limitations on suite size and design in the 2000 LSC limit their efficiency and the ability for facilities to accommodate suites in their building space, which results in undue burden. 

    • The 2006 LSC, began to include additional provisions to further accommodate the use of suites, and continue to be reflected in sections 18/19.2.5.7 of the 2012 LSC. 

    • CMS is permitting a waiver to allow: (1) one of the required means of egress from sleeping and non-sleeping suites to be through another suite, provided adequate separation exists between suites; (2) one of the two required exit access doors from sleeping and non-sleeping suites to be into an exit stair, exit passageway, or exit door to the exterior; and (3) an increase in sleeping room suite size up to 10,000 ft. The provider/supplier must be in compliance with all other applicable 2000 LSC suite provisions, as well as with sections 18/19.2.5.7 of the 2012 LSC.

  6. Extinguishing Requirements

    • Section 9.7.5 of the 2000 LSC requires all automatic sprinkler and standpipe systems to be inspected, tested, and maintained in accordance with the 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems. Sections 2-3.3 and 5-3.2 of the 1998 NFPA 25 require the quarterly testing of vane-type and pressure switch type waterflow alarm devices, and weekly testing of electric motor-driven pump assemblies. Reducing the frequency of testing requirements will reduce cost burden. 

    • The 2011 NFPA 25 began allowing for testing of vane-type and pressure switch type waterflow alarm semiannually and electric motor-driven pump assemblies monthly. 

    • CMS is permitting a waiver to allow for the reduction in the testing frequencies for sprinkler system vane-type and pressure switch type waterflow alarm devices to semiannual and electric motor-driven pump assemblies to monthly. The provider/supplier must be in compliance with all other applicable 1998 NFPA 25 (as referenced in section 9.7.5 of the 2000 LSC) testing provisions, as well as with sections 5.3 and 8.3 of the 2011 NFPA 25. 

  7. Clean Waste and Patient Record Recycling Containers

    • Sections 18/19.7.5.7 of the 2000 LSC limit the size of trash collection containers to 32-gallons when located outside of a hazardous storage area and not attended. Recycling containers used for clean waste (e.g., bottles, cans, paper) pose a lower fire risk than trash containing grease, oil, or flammable liquids. Allowing the size of container used for recycling to increase will reduce the number of trash receptacles and hazardous storage areas required, which will reduce undue cost burden. 

    • The 2012 LSC began allowing containers used solely for recycling clean waste or for patient records awaiting destruction outside a hazardous storage area to be a maximum capacity of 96-gallons. 

    • CMS is permitting a waiver to allow the increase in size of containers used solely for recycling clean waste or for patient records awaiting destruction outside of a hazardous storage area to be a maximum of 96-gallons. The provider/supplier must be in compliance with sections 18/19.7.5.7.2 of the 2012 LSC.

 



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