Categorical Waivers and the New 2012 Life Safety Code

10112[1]By now most of you have heard that CMS finally adopted the 2012 Life Safety Code, effective July 4, 2016, which is 60 days from the date CMS posted their final rule (May 4, 2016). While nearly everyone is excited and happy that CMS finally published their final rule, it is raising some questions that previously may not have been addressed.

I received an email from a reader that asked the following:



Since the 2012 edition of the Life Safety Code has now been adopted by CMS, what implications does that have for organizations that have categorical waivers adopted…and are anxiously awaiting our survey.  We are due for survey before August 31, 2016.   I realize we need to comply by July 4th, so we are in an interesting time slot.  Any guidance you could offer would be appreciated.  Basically, do we keep the waivers until July 4th or what?

This adoption of the 2012 Life Safety Code by CMS does not have any effect on the categorical waivers already invoked by the hospital. Since the concept of invoking a categorical waiver is to be in compliance with a particular section of the 2012 LSC, once the 2012 LSC becomes effective, the categorical waivers no longer apply. They simply ‘go away’ or dissolve.

Now… CMS’s final rule will require hospitals to be compliant with the 2012 Life Safety Code by July 4, 2016. But in reality, this should not be a burden for most hospitals since most of the differences between the 2000 LSC and the 2012 LSC are in the favor of the facilities… meaning there are less restrictions rather than more restrictions.

However, there are a few changes that are more restrictive with the 2012 LSC, such as:

  • All swinging fire-rated doors must be tested and inspected annually;
  • Temporary construction barriers must be 1-hour fire rated (or non-rated if the construction area is fully sprinklered; tarps cannot be used);
  • Pressuring reducing valves on sprinkler systems need to be inspected quarterly.

Technically… CMS is saying the hospital needs to be compliant with these ‘more restrictive’ issues by July 4, 2016. But in reality, there will be some unstated ‘adjustment’ time where the accreditation organizations (AOs) will show leniency towards the more restrictive requirements. How much time? No one knows, but if past indicators are predictors of the future, I would not be surprised that the AOs will not enforce the new requirements until August or September, or maybe even the first of the year.

That’s just my opinion, but that is based on the knowledge that the AOs cannot make changes to their accreditation manual until CMS approves it and CMS takes 60 days to review and approve an AO manual. It would take 30 – 60 days for the AO make their changes and submit them to CMS. So… Assuming the AOs submit their revised manuals to CMS in June, and CMS takes 60 days to approve it… It looks like August or September before the AO can enforce the new requirements of the 2012 LSC.

But… I suggest you get started on compliance with these new more restrictive requirements, if you haven’t already. If you start today, you may be in full compliance with the additional requirements by July 4, 2016.