ASHE News

FAQs on the new CMS Conditions of Participation

Published:

Subject Matter: Article | Topics: Codes and standards

In 2016, the Centers for Medicare & Medicaid Services (CMS) adopted new Conditions of Participation that incorporated the 2012 editions of NFPA 101 and NFPA 99. CMS recently provided ASHE with the following guidance on some frequently asked questions regarding the new CMS requirements.

Positive latching

Will doors to toilet rooms and bathing rooms now have to be positive latching? If so, will this requirement be retroactive? Currently it is common practice – and had previously been allowed – to not have positive latching on these rooms. Many toilet and bathing rooms currently have reverse hardware so that doors could be opened to avoid entrapment issues. The revised language on roller latches seems to prohibit that practice, spurring the question.

Answer: If the toilet or bathing room is accessible from a corridor, it has to have positive latching. The requirement doesn’t require locking, just positive latching, in this case. If the toilet or bathing room is accessible from the inside of a room, positive latching would not be required.

Added: 5/30/17


Smoke exhaust fans

Can hospitals decommission smoke exhaust fans that they have in their operating rooms?

Answer: Under certain conditions, they can be decommissioned.

Facility Conditions Options

Existing occupancy with smoke control installed

  • Maintain to edition of code at installation
    OR
  • Completely remove smoke exhaust fans only after the facility is in full compliance with 2012 NFPA 99

Existing occupancy without smoke control installed

  • No smoke control system required if the facility is in full compliance with 2012 NFPA 99

New occupancy

  • No smoke control system required if the facility is in full compliance with 2012 NFPA 99

Please note that this answer does not address medical plume evacuation, which remains a requirement in the 2012 edition of NFPA 99.

Added: 5/30/17


Code editions

Many states have adopted current editions of NFPA 72, 13 and 70. Are facilities able to comply with the current editions instead of the older editions required by CMS?

Answer: A facility may have to comply with current editions due to licensure concerns, but CMS surveys on the codes it has adopted through its regulatory process—in this case, the 2012 editions of NFPA 101 and NFPA 99.

Added: 5/30/17


ASHRAE 170

Do hospitals have to retroactively comply with all of the ASHRAE 170 requirements?

Answer: Existing facilities must comply with requirements that were adopted by CMS at the time of construction, or they can choose to comply with 2012 HVAC requirements found in NFPA 99.

Added: 5/30/17


Fire watch

When a building is being constructed and is separated by a proper barrier from an existing occupancy, does a fire watch need to be conducted for the building under construction? Fire watches are not typical during construction of new buildings. Would a proper fire barrier preclude the need for a fire watch in this situation?

Answer: If the barrier is a proper fire barrier, the barrier would be adequate. However, the barrier could not be a simple plastic barrier with plywood door – it would need to be a proper fire barrier. Also, if the construction affects any existing fire protection features such as a sprinkler or the fire alarm system, a fire watch would likely be required.

Added: 5/30/17


CORRIDOR PROTRUSIONS

Question: The 2012 Life Safety Code restricts items from protruding farther than 4 inches into the corridor. Does this mean that all FE cabinets that protrude 4.5 inches to 5 inches into the hallway need to be removed and replaced with slimmer cabinets?

Answer: 18/19.2.3.4 allows non-continuous projections that do not exceed 6 inches. However, keep in mind that the Americans with Disabilities Act only allows projections up to 4 inches.  Projections more that 4 inches need to allow for cane detection at floor level.

–Chad Beebe, AIA, FASHE, ASHE Deputy Executive Director of Advocacy


FGI GUIDELINE ADOPTION

Question: Will CMS and the Joint Commission reference Facility Guidelines Institute Guidelines and the ASHRAE 170-2008 code for protected environments?

Answer: CMS does not reference the FGI Guidelines.  However, CMS did adopt NFPA 99, and that document references the 2008 edition of ASHRAE 170. The Joint Commission is looking at updating its standards to the 2014 edition of the FGI Guidelines, which would include a reference the 2013 edition of ASHRAE 170, although they may choose to reference the 2008 edition instead to avoid any conflicts. Joint Commission enforcement of the FGI Guidelines only occurs in states that do not have a state standard referenced. ASHE has a map that shows the editions of the FGI Guidelines adopted in each state.

–Chad Beebe, AIA, FASHE, ASHE Deputy Executive Director of Advocacy

Added: 7/25/16


WAIVERS

Question: What will happen with the waivers that were in place prior to CMS adoption of the 2012 edition of NFPA 101 and NFPA 99?

Answer: There are currently two types of waivers, situation- or facility-specific waivers and categorical waivers. Situation- and facility-specific waivers are unique to a facility and only apply for one year before needing to be renewed with CMS (unless the condition is fixed). Categorical waivers apply to all facilities and do not expire.

It is likely that a categorical waiver that was being used to comply with a provision of the 2012 edition of the LSC will no longer be needed.  However, this does not affect any facility specific waivers that you may have. If you opted for any , you will likely need to keep those on file until your next CMS survey. At that time, you can discuss the need for the waiver should the code have changed and determine if you need those waivers going forward.

However, this does not affect any facility specific waivers that you may have. If you have any, you will likely need to keep those on file until your next CMS survey. At that time, you can discuss the need for the waiver should the code have changed and determine if you need those waivers going forward.

–Chad Beebe, AIA, FASHE, ASHE Deputy Executive Director of Advocacy


SUITE SIZES

Question: Does the allowance for larger suite sizes apply to existing health care occupancies as well as new health care occupancies?

Answer: Yes. NFPA 101, Chapter 19, Existing Healthcare Occupancies provides for larger suite sizes compared to the 2000 edition, as does Chapter 18 for New Healthcare Occupancies.

--Tim Adams, FASHE, CHFM, CHC, ASHE Director of Leadership Development


4-HOUR TESTING

Question: Will CMS require performing a 4-hour test every three years on generators providing power to the essential electrical system?

Answer: The 2012 edition of NFPA 101 references the 2010 edition of NFPA 110: Standard for Emergency and Standby Power Systems. The 2010 edition of NFPA 110 does require a 4-hour test of generators every three years, and therefore we anticipate that CMS will require that this test be performed. Most health care facilities that have an essential electrical system using a generator as the emergency source have already been performing this test.

--Tim Adams, FASHE, CHFM, CHC, ASHE Director of Leadership Development


SMOKE EVACUATION

Question: Does the new CMS rule require hospitals or ambulatory surgical centers to provide smoke evacuation systems?

Answer: No. CMS did not adopt this requirement in its final rule. This requirement was removed from NFPA 99 for several reasons—including the issues regarding the complexity of such a system functioning within an operating room with varying types of airflow schemes. While fires are an occurrence in operating rooms, the provision was originally included in NFPA 99 back when operating rooms were not required to be sprinklered and we still used flammable anesthetics. The fires in operating rooms tend to be fast burning and fueled by limited amounts of surgical prep alcohol and oxygen saturation of materials. Both conditions typically produce low volumes of smoke. Smoke evacuation systems would be impracticable and ineffective, and activation of such system could pose infection control risks to other patients in other operating rooms.

–Chad Beebe, AIA, FASHE, ASHE Deputy Executive Director of Advocacy

Added: 6/7/16


OCCUPANCY CLASSIFICATION

Question: If my hospital currently has an ambulatory surgical center that is built as a Business Occupancy do I have to upgrade it to an Ambulatory Health Care Occupancy?

Answer: If your ambulatory surgical center provides services that renders the patient incapable of self-preservation, uses general anesthesia, or provides emergency services that one would expect to receive patients that due to the nature of their injury are incapable of self-preservation the building needs to be upgraded to Ambulatory Health Care Occupancy.  It is permissible to upgrade to a higher level Health Care Occupancy. 

–Chad Beebe, AIA, FASHE, ASHE Deputy Executive Director of Advocacy


HUMIDITY

Question: Is the 20% humidity categorical waiver still needed?

Answer: Yes for Existing, No for New construction. The 2012 NFPA 99 HVAC requirements would not be applicable to existing construction or equipment, therefore existing systems must either fully comply with ASHRAE 170 requirements or comply with the NFPA 99 ventilation standards adopted by CMS at the time the system was installed (e.g., 1999 NFPA 99).  In this example, an existing anesthetizing location must either comply with the 1999 NFPA 99 humidity requirement of 35%, elect the CMS categorical waivers to meet 20% (i.e., S&C 13-25, S&C 15-27), or be fully compliant with the 2012 NFAP 99 HVAC requirements.

–Chad Beebe, AIA, FASHE, ASHE Deputy Executive Director of Advocacy

Added: 2/6/17