Using Certain Sections of the 2012 Edition of the Life Safety Code

What process should be used to take advantage of the recent CMS correspondence that deals with allowing mobile equipment, such as patient lifts and gurneys in the corridors? To refresh your memory, CMS S&C Letter 12-21 issued March 9, 2012 allows hospitals and nursing homes the opportunity to start using certain sections of the 2012 edition of the Life Safety Code, by considering requests for waivers to the current 2000 edition of the Life Safety Code, without the organization having to show an “unreasonable hardship”.

The sections that CMS will allow, are (references are to the 2012 edition of the LSC):

  • 18/19.2.3.4 which allows projections into the means of egress corridor width for wheeled equipment and fixed furniture
  • 18/19.3.2.5.2 though 18/19.3.2.5.5 which allows certain types of alternative kitchen cooking arrangements
  • 18/19.5.2.3(2), (3), and (4) which allows the installation of direct vent gas fireplaces in smoke compartments containing patient sleeping rooms and the installation of solid fuel burning fireplaces in areas other than patient sleeping areas
  • 18/19.7.5.6 which allows the installation of combustible decorations on walls, doors, and ceilings.

If you are Joint Commission (TJC) accredited, the process to follow, is to request a Traditional Equivalency from TJC to allow you to begin using the 2012 edition of the LSC on those 4 or 5 issues identified in the CMS S&C Letter 12-21. TJC requires that you have a written opinion from one of the following three individuals, who states that you meet the expectations in the 2012 edition of the LSC:

  • Local AHJ on fire safety
  • Registered architect
  • Fire safety engineer

You then write a cover letter requesting a Traditional Equivalency and submit it along with the written opinion from one of the above individuals. TJC should approve your Traditional Equivalency request, and then you may begin using the new 2012 references. The important thing to understand in this issue, is you do not request a waiver from CMS to use the 2012 edition until such time you are cited by a state agency representing the CMS. Then, as part of your Plan of Correction, you submit a waiver request through the state agency to the CMS Regional Office who will review and probably approve your request. For many of the organizations out there, you may never get cited by a state agency representing CMS before the new 2012 edition of the LSC is adopted, which is hopefully within the next 24 months.

CMS Releases Memo Allowing Waivers for Certian References of the 2012 LSC

The Centers for Medicare & Medicaid Services (CMS) released a new memo (S&C-12-21-LSC) to their State Survey Agencies on Friday, March 9, 2012. In the memo was instructions on how healthcare facilities can apply for waivers to the 2000 edition of the NFPA 101 Life Safety Code (LSC), which will allow the healthcare organizations to take advantage of select references of the new 2012 edition of the LSC.

This memo describes the process that a healthcare organization can request a waiver from CMS on the following issues:

  • Increasing the amount of wall space that may be covered by combustible decorations
  • Permitting gas fire places in common areas
  • Permitting permanent seating groupings of furniture in corridors
  • Allowing kitchens which serve less than 30 residents, to be open to the corridor as long as they are contained inside a smoke compartment

CMS says the waivers will be applicable to both new and existing conditions, and organizations are not required to demonstrate ‘unreasonable hardship’ as they would with a normal waiver request. It is apparent that the intent of the change to allow waiver requests for these four items, is directed towards the nursing home industry, but it does apply to all healthcare occupancies, including hospitals. While it is not likely that an acute-care hospital would be interested in pursuing the waiver request procedure for just these 4 items, it is possible that a specialty hospital, such as rehab or facility based hospice, may be interested.

Some individuals in the healthcare industry are heralding this announcement as a step towards CMS adopting the 2012 edition of the LSC. This certainly looks favorable in this regard, but since there really isn’t any ‘meat’ on this bone for the majority of the hospitals in the nation, I wouldn’t get too worked up about this.

I’m often asked when will CMS finally adopt the 2012 edition of the LSC, and the honest answer is, no one knows  the precise date. However, last October CMS did announce that they are reviewing the 2012 edition for consideration of adopting it, which is their vernacular indicating they will. History tells us they will take anywhere from 18 months to 3 years to adopt it, as they must go through many stages of public review and comment. So, that puts us in 2013 or 2014 for the ‘best guess’.