CMS Amends Fire Safety Standards – Impacts Hospice Inpatient Facilities
May 12, 2016 12:41 PM
The Centers for Medicare & Medicaid Services (CMS) has released a final rule amending fire safety standards for specific Medicare and Medicaid-participating facilities (including hospice inpatient facilities), adopting the 2012 edition of the Life Safety Code (NFPA 101), and eliminating regulatory references to earlier editions of the Life Safety Code. Finally, the regulation adopts the 2012 edition of the Health Care Facilities Code (NFPA 99), with some exceptions. The changes were proposed in April 2014 and will become effective July 5, 2016.
The National Association for Home Care & Hospice (NAHC) is analyzing the final rule and will be providing additional information in the coming weeks. In the interim, following are the text changes to the Hospice Conditions of Participation at 418.110 as published by CMS in the final rule:
§418.110 Condition of participation: Hospices that provide inpatient care directly.
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(d) * * *
(1) * * *
(i) The hospice must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.)
(ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
(2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospice facility, but only if the waiver will not adversely affect the health and safety of the patients.
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(4) A hospice may place alcohol-based hand rub dispensers in its facility if the dispensers are installed in a manner that adequately protects against access by vulnerable populations.
(5) When a sprinkler system is shut down for more than 10 hours, the hospice must:
(i) Evacuate the building or portion of the building affected by the system outage until the system is back in service, or
(ii) Establish a fire watch until the system is back in service.
(6) Buildings must have an outside window or outside door in every sleeping room, and for any building constructed after [July 5, 2016] the sill height must not exceed 36 inches above the floor. Windows in atrium walls are considered outside windows for the purposes of this requirement.
(e) Standard: Building Safety. Except as otherwise provided in this section, the hospice must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6).
(1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not apply to a hospice.
(2) If application of the Health Care Facilities Code required under paragraph (e) of this section would result in unreasonable hardship for the hospice, CMS may waive specific provisions of the Health Care Facilities Code, but only if the waiver does not adversely affect the health and safety of patients.
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(q) The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202–741–6030, or go to:
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Standards for Health Care Facilities Code of the National Fire Protection Association 99, 2012 edition, issued August 11, 2011.
(ii) TIA 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011;
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.
As part of a press release that was issued concurrent with the final rule, CMS stated the following:
“This final rule meets health care facilities’ desire to modernize their environments while also ensuring the necessary steps to provide patients and staff with the appropriate level of safety…Health care facilities can now be more home-like while ensuring that the most modern fire protection practices are in place.”
The provisions in this final rule cover construction, protection, and operational features designed to provide safety for Medicare beneficiaries from fire, smoke, and panic. Some of the main requirements laid out in this final rule include:
Health care facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date.
Health care facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than ten hours.
The provisions offer LTC facilities greater flexibility in what they can place in corridors. Currently, they cannot include benches or other seating areas because of fire code requirements limiting potential barriers to firefighters. Moving forward, LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms (such as pictures and other items of home décor).
Fireplaces will be permitted in smoke compartments without a one hour fire wall rating, which makes a facility more home-like for residents.Cooking facilities now may have an opening to the hallway corridor. This will permit residents of inpatient facilities such as nursing homes to make food for themselves or others if they choose to, and, if the patient does decide to make food, facility staff is able to provide supervision of the patient.
For ASCs, all doors to hazardous areas must be self-closing or must close automatically. Additionally, alcohol based hand rub dispensers now may be placed in corridors to allow for easier access.