Compliance News: CMS Life Safety Code® Waivers

By Dean Samet, CHSP






There are times when certain provisions of the NFPA 101® Life Safety Code® might not be met. The Centers for Medicare & Medicaid Services has a “waiver” process per 42 CFR 483.70(a) (2) specifying that a waiver may be granted where it would not adversely affect resident health and safety (while a reasonable degree of fire safety is being provided) and it would impose an “unreasonable hardship” on the facility to meet specific LSC provisions. When it is not readily practical for a health care facility to comply fully with all of the specific requirements of the LSC, the fire authorities having jurisdiction (AHJs) may evaluate the degree of enforcement necessary to provide a reasonable measure of safety and an equivalent degree of protection.

The NFPA 101 is the code for safety to life from fire in buildings and structures. The basic requirement for facilities participating in the Medicare and Medicaid programs is compliance with the 2000 edition of the LSC. This edition is also referenced by the various hospital-accrediting bodies granted deeming authority and recognized by CMS such as The Joint Commission (TJC), American Osteopathic Association (AOA), and Det Norske Veritas Healthcare (DNVHC), as well as many local and state fire marshals across the country.


The LSC provides that the AHJ shall determine the adequacy of protection provided for life safety from fire in accordance with the provisions of the LSC. While the State Survey Agency’s (SA) Life Safety Code surveyor may recommend waivers, only CMS Regional Offices (ROs) can grant the waivers. Facilities with waivers of the health occupancy provisions of the LSC or with an acceptable Plan of Correction are considered “in compliance” by CMS.

In making a decision to grant a waiver, CMS considers whether the “intent” of the LSC is met. The requirements of the LSC are directed to a series of factors or areas such as:

1. Fire Load
2. Fire Containment
3. Fire Extinguishment
4. Evacuation
5. Operating Features

The following should also be considered and evaluated by the fire AHJ:

1. Staffing considerations such as staff-patient ratios, staffing patterns, and scope of staff training to handle fire emergencies;
2. Availability and adequacy of compartment and horizontal exits, such as areas to hold patients during a fire emergency;
3. Location and number of ambulatory and nonambulatory patients;
4. Availability, extent, and type of automatic fire detection and fire extinguishment systems provided in the facility;
5. Means for notifying the fire department in case of fire; and,
6. Effectiveness of fire department (e.g., types of equipment available; number of personnel normally responding to a fire call; distance to the nearest fire station; and normal response time of the fire department).

The total fire safety of a building is dependent upon the combined effects of the above listed factors. Each building is unique from a fire safety viewpoint and should be evaluated by the fire AHJ(s) on its own merits. Not all requirements are of equal importance in all situations. If it can be established that a particular LSC deficiency does not materially affect the overall level of life safety, it is reasonable to hold that the fire safety characteristics of the health care facility have not been compromised and that the “intent” of the LSC has been met.

In cases in which patient safety would not be adversely affected by a waiver, the following factors should be considered in evaluating the issue of unreasonable hardship:

• Estimated cost of the installation;
• Extent and duration of the disruption of normal use of patient areas resulting from construction work;
• Estimated period over which cost would be recovered through reduced insurance premiums and increased payment related to cost;
• Availability of financing; and,
• Remaining useful life of the building

Please note that an LSC waiver granted by CMS for any Life Safety Code deficiencies may not necessarily be accepted by your accrediting organization(s) such as TJC, DNV, or the AOA. Conversely, LSC “equivalencies” granted by an accrediting body, such as The Joint Commission and its “equivalency processes,” may not necessarily be accepted or recognized by CMS. When requesting a Life Safety Code waiver from CMS for any LSC deficiencies, it is recommended to also submit an equivalency request to your accrediting organization (per their specific requirements) and vice versa.

For additional information on CMS’s Life Safety Code Waiver process, please go to: http://www.cms.gov/CertificationandComplianc/11_LSC.asp or contact your CMS Regional Office.


http://www.ssr-inc.com/pdfs/Nov-Dec%202011%20CompNews%20-%20reduced.pdf