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HCI Urges Facility Managers to Review CMS’ Final Rule on 2012 Life Safety Code Adoption

  by Megan Headley | May 24, 2016
  The Health Care Institute advises all professionals involved in the planning, design, construction, engineering and operations of healthcare facilities to take note of the Centers for Medicare & Medicaid Services’ (CMS) final rule adopting the 2012 editions of NFPA’s Life Safety Code and Healthcare Facilities Code.

“Widely anticipated for several years, this has enormous impact on surveys in process and those about to occur,” says Mike Wood, president of the HCI. “All of the previously issued waivers will need to be converted and each of them assessed for applicability not only to the new CMS rules but your local authorities having jurisdiction as well.”

As of July 5, CMS is adopting certain provisions of the 2012 editions of these two codes to bring its requirements up to date. While many healthcare facilities have begun using the 2012 edition of the LSC in expectation of this update, it is critical to note that CMS is not adopting every provision of the codes. For example, CMS notes in its requirements for hospitals the following “clarifications”:

  •  “We are clarifying that the prohibition on roller latches applies only to doors to corridors and to rooms containing flammable or combustible materials.

  • We are clarifying that all outpatient surgical departments must meet applicable provisions in Ambulatory Health Care occupancy chapter, regardless of the number of patients served.

  • We are revising the requirements for the shutdown of a sprinkler system for an extended period of time.

  • We are removing the requirement for installation of a dedicated air supply and exhaust system in windowless anesthetizing locations.

  • We are revising the window sill requirement for new construction only to indicate that such sills must not be higher than 36 inches above the floor.”

An additional change is that the final CMS rule incorporates by reference a number of Tentative Interim Amendments issued to the codes.

CMS notes in its final rule that many commenters expressed confusion as to why the NFPA 99 is not being adopted in full. Its response is that the organization does not have the authority to regulate the topics addressed in Chapters 7 (Information Technology and Communications Systems for Health Care), 8 (Plumbing) and 13 (Security Management), and that the content of Chapter 12 (Emergency Management) is already addressed in a separate rule for emergency preparedness.

Accreditation organizations also are complying to these updates, making it imperative that healthcare facilities review the updated requirements. In its May 11, 2016, newsletter, the Joint Commission noted that it will follow suit and begin surveying to the 2012 LSC as of July 5 as well. The newsletter notes, “The rule adopts most of the proposals that CMS made in 2014, however, CMS removed a proposed requirement for hospitals to install smoke-purging systems in operating rooms. George Mills, director of engineering, The Joint Commission, said the proposal was ‘unnecessary’ and ‘prohibitively expensive.’”

Because of these differences, it’s important that healthcare facility managers carefully review the final CMS rule and understand its potential impact on their facilities.

“We anticipate that many municipalities and related AHJs will be out of sync with the new rules for a period of time—it’s anyone guess what that period may be—but all of us need to take advantage of educational opportunities on these updates to become very familiar with the trending issues as soon as we can,” Wood says. He adds, “July 5 is only a few weeks away. There is no time to waste on this one!”

Facility managers looking for more information on compliance have a number of resources available, including the following:

  • CMS has a fact sheet detailing some of the key changes for healthcare facilities.

  • NFPA offers a page of resources on the updated CMS requirements.

  • HCI is set to host its next Hospital & Medical Facilities Summit in August. This event will features Life Safety Code specialists able to answer your questions on what this update means for you.