Q: Which edition of NFPA 110 are we expected to follow? I read that we’re expected to comply with the 1999 edition, the 2005 edition and now the 2010 edition. Which is correct?
A: The 2000 Life Safety Code references the 1999 edition of NFPA 110. The 1999 edition of NFPA 99 also references the 1999 edition of NFPA 110. Since CMS is still on the 2000 LSC, then the 1999 edition of NFPA 110 governs. However, Joint Commission standards references the 2005 edition of NFPA 110 for the 3-year, 4-hour load test, because this load test is not required in the 1999 edition of NFPA 110. Apparently, the accreditor feels the 3-year, 4-hour load test has value and wants their clients to comply with the load test. Joint Commission can do this since the addition of the 3-year, 4-hour load test is not in difference to the 1999 edition of NFPA 110; it is just an addition, so CMS allows it. HFAP and DNV have written similar standards that reference the 3-year, 4-hour load test found in the 2005 edition of NFPA 110.
But last year, CMS issued categorical waivers in their S&C memo 13-58 that will permit hospitals, critical access hospitals, long-term care facilities, ambulatory surgical centers, and inpatient hospices to use the provisions found in the 2010 edition of NFPA 110 immediately without waiting for the new LSC to be adopted. The 2010 edition of NFPA 110 will allow you to reduce the annual load test from 2-hours down to 90-minutes when the monthly load tests do not meet the 30% load capacity of the nameplate value. All of the accreditation organizations recognize and support this CMS position, but be aware that some state agencies do not.
The 2010 edition of the NFPA 110 is referenced by the 2012 edition of the Life Safety Code and will become the rule once the 2012 LSC is adopted. So, for the most part, the 1999 edition of NFPA 110 is the one to use, unless you’re Joint Commission or HFAP accredited, then you must also follow the 2005 edition of NFPA 110 for the 3-year, 4-hour load test. Also, you have the option to use the 2010 edition of NFPA 110 for the annual load test through the use of the CMS categorical waivers. Sounds confusing, but everyone will be on the 2010 edition of NFPA 110 once CMS adopts the 2012 edition of the LSC.
To download your own copy of the CMS S&C memos, go to: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html