The 2012 editions of NFPA 101, the Life Safety Code® and NFPA 99, the Health Care Facilities Code, have been adopted by the Centers for Medicare & Medicaid Services (CMS).  The adoption will be published in the Federal Register on Wednesday, May 4, with an adoption date of July 5, 2016.

CMS is adopting these codes, with several exceptions, including:

  • The following NFPA 99 chapters are not included in the adoption:
    • Information Technology (Chapter 7)
    • Plumbing (Chapter 8)
    • Emergency Management (Chapter 12)
    • Security (Chapter 13)
  • Positive latching hardware must be present on corridor doors and doors to rooms containing flammable/combustible materials; roller latches are prohibited.  This exception was also taken to the currently adopted 2000 edition of the Life Safety Code®, so does not represent a change.
  • CMS may continue to waive specific provisions of the Life Safety Code® based on a recommendation by a state survey agency or accrediting organization if compliance would result in unreasonable hardship to the healthcare organization and the waiver will not adversely affect the health and safety of the patients. 
  • Alcohol-based hand rub dispensers in hospital facilities must be installed in a manner that adequately protects against inappropriate access.  This CMS requirement differs from the Life Safety Code, which doesn’t have any requirements against inappropriate access to the dispensers.
  • Hospitals have 2 options when a sprinkler system is shut down for more than 10 hours: (1) Evacuate the building or portion of the building affected by the sprinkler system outage until the system is back in service; (2) Establish a fire watch until the sprinkler system is back in service.  Currently, a fire watch must be established when the sprinkler system (or fire alarm system) is shut down for 4 or more hours during a 24 hour period, so this is a more lenient requirement.
  • Every sleeping room must have an outside window or outside door.  In any building constructed 60 days past the publication date of the rule, the sill height must not exceed 36 inches above the floor.  Windows in the atrium walls are considered outside windows.  Sill height requirements do not apply to newborn nurseries or rooms intended for less than 24-hour occupancy.  Special nursing care areas of new occupancies must not have sill heights that exceed 60 inches.

Adoption of the 2012 Life Safety Code® will render any previously adopted categorical waivers related to that code unnecessary.  Note, however, that the waivers related to OR relative humidity and use of relocatable power taps will still be required.

Please note, according to the CMS, health care providers affected by this rule must comply with all regulations within 60 days of the publication date of today’s final rule, which is May 4, 2016, unless otherwise specified in the final rule.

For additional resources, check out these links:

CMS Press Release   |   ASHE Resources

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