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

Members | September 19, 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. 

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.