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):
- 18/126.96.36.199 which allows projections into the means of egress corridor width for wheeled equipment and fixed furniture
- 18/188.8.131.52.2 though 18/184.108.40.206.5 which allows certain types of alternative kitchen cooking arrangements
- 18/220.127.116.11(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
- 18/18.104.22.168 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.