By Chad Beebe, AIA, SASHE, ASHE Deputy Executive Director of Advocacy
What does the adoption of the 2012 edition of NFPA 101 mean to hospitals?
The Centers for Medicare & Medicaid Services (CMS) has adopted the 2012 edition of NFPA 101: Life Safety Code® through a new rule changing its Conditions of Participation (CoPs). For hospitals and other health care providers that participate in the Medicare and Medicaid programs, this change means that they will need to comply with the 2012 edition of the code to meet the CoPs. The change is effective July 5, and comes after years of CMS considering the move to a more updated standard. The new CoPs adopt the 2012 editions of both NFPA 101 and NFPA 99: Health Care Facilities Code. However, the CMS rule makes certain changes to the NFPA codes. This article outlines some of those changes included in the rule.
What is included in the final rule?
There are many changes between the 2000 edition of NFPA 101 and the 2012 edition. The 2012 edition contains multiple improvements made over the 12-year span between editions, and incorporated lessons learned from major events such as Hurricanes Katrina and Sandy, blackouts in the Northeast, the Sept. 11, 2001 terrorist attacks, and other events. An ASHE monograph details the differences in code requirements between the 2000 edition and 2012 edition.
CMS made some changes—but not many—to the 2012 edition of the codes when adopting them as part of their CoPs. For this article, we will only focus on the differences between the 2012 edition of NFPA 101 and NFPA 99 and the new CoPs.
When CMS announced this new CoPs via the Federal Register, the document CMS posted was 133 pages and most of the document explains the history of how CMS arrived at its decisions regarding the final rule. If you are not careful, reading some of the early parts of this document without understanding the context could lead you to some wrong conclusions about what will be required. For clarity, this article focuses on the CoPs themselves—not the background or items that CMS previously considered.
The following are links to specific parts of the final rule for certain provider types:
- PART 403—SPECIAL PROGRAMS AND PROJECTS
- PART 416—AMBULATORY SURGICAL SERVICES
- PART 418—HOSPICE CARE
- PART 460—PROGRAMS OF ALL INCLUSIVE CARE FOR THE ELDERLY (PACE)
- PART 482—CONDITIONS OF PARTICIPATION FOR HOSPITALS
- PART 483—REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES
- PART 485—CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
How should I read this rule and interpret what it says?
In this section of the article, we will walk through the rule to show which regulations apply to hospitals.
Ambulatory Surgical Centers
If you work at a hospital, I suggest that you avoid the temptation to look at PART 416 if you have an Ambulatory Surgical Center (ASC). Your ASC may be billing Medicare under the PART 482—CoPs for Hospitals. You should check with your billing department to determine whether they are billing hospital provider status for the services in that ASC building. If they bill under hospital provide status, the ASC should follow hospital CoPs. Otherwise, Part 416 may be appropriate.
The Hospital Physical Environment
CoPs for the hospital physical environment start with Part 482.41 Condition of Participation: Physical Environment. If you review this section of the CoPs, you will see that CMS adopts the Life Safety Code in addition to several Tentative Interim Amendments (TIAs); specifically TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4. ASHE will be providing more information on these TIAs in an upcoming article.
You can also see that CMS has outlined specific additions or changes to the Life Safety Code within this section. Each of these sections is numbered and includes regulatory language. Below are the requirements as outlined in the CMS CoPs, with additional commentary from ASHE regarding each one:
§ 482.41 (b)(1)(ii) Notwithstanding paragraph (b)(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.
ASHE comments: The second provision of this regulation is the prohibition of roller latches on certain doors. CMS has long prohibited this. Until CMS sees the benefit to life safety of having roller latches in certain locations (such as psychiatric care), we expect roller latches to continue to be prohibited out of concern over their performance in a fire corridor doors and doors to rooms containing flammable or combustible materials.
Roller latches are allowed in fully sprinkled buildings, but because hospitals use a defend-in-place approach, there a few minor revisions that CMS has made. First, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on these doors in health care facilities because we use defend-in-place strategies. An important aspect of the R.A.C.E method (rescue, alarm, contain or confine, extinguish or evacuate) of defending-in-place is to contain the fire, which may simply include closing the door to the room of origin.
§ 482.41 (b)(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 hospital, but only if the waiver will not adversely affect the health and safety of the patients.
ASHE comments: CMS has always had the authority to waive requirements, or at least has always included that authority in their standard practice. This will be beneficial for specific situations where full compliance in an existing building would be over burdensome and impractical. It is unclear whether the process will change from the previous waiver process, but it will likely require a citation of the situation first then require a re-application for the waiver each year or survey.
§ 482.41 (b)(7) A hospital may install alcohol-based hand rub dispensers in its facility if the dispensers are installed in a manner that adequately protects against inappropriate access;
ASHE comments: At first read, many people think that this section on alcohol-based hand rubs is already covered in the Life Safety Code. But this section of the CMS CoPs actually addresses a problem not addressed in NFPA 101: access to alcohol-based hand rubs within the facility. There have been attempted suicides and fires started either accidently or maliciously using ABHR provided in the facility. This is a serious safety issue and ASHE expects this will be looked at during surveys.
§ 482.41 (b)(8) When a sprinkler system is shut down for more than 10 hours, the hospital 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.
ASHE comments: This sprinkler shut down requirement is exactly as found in NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. If your sprinkler system is shut down for more than 10 hours, you will be expected to either evacuate or do a fire watch for that extended period. Some might wonder why this requirement is in the CoPs if it is already included in (and exactly the same as) NFPA 25, which is a reference code. That is a good question, and I suspect it has more to do with the rule making process and the late change from 4 to 10 than any technical merit.
§ 482.41 (b)(9) 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.
(i) The sill height requirement does not apply to newborn nurseries and rooms intended for occupancy for less than 24 hours.
(ii) The sill height in special nursing care areas of new occupancies must not exceed 60 inches.
ASHE comments: Many are struggling to understand the need for this requirement, especially in a high rise facility where windows are not required to be accessible by fire service. It’s important to note that this only affects new construction. Existing sleeping rooms will be required to have an outside window or door.
§ 482.41 (c) The next section of the CoPs covers the direct adoption of NFPA 99, which includes all chapters except 7, 8, 12, and 13, and includes a provision which gives CMS the authority to waive specific provisions of the code but only if the waiver does not adversely affect the health and safety of patients. CMS also adopted TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6 for NFPA 99. ASHE will be providing more information on these TIAs in an upcoming article.
What about Previous Categorical Waivers?
If your facility has been taking advantage of the categorical waivers CMS offered when it required compliance with the 2000 edition of NFPA 101, you will have a leg up when it comes to complying with the 2012 edition. Most of the waivers were provided by CMS to provide relief while the process of adopting the 2012 edition was underway. Many facilities have taken full advantage of the waivers, which allowed compliance with many portions of the 2012 code such as suite sizes, door locking arrangements, and more. After July 5, health care facilities will no longer have to request these waivers, include it in policies, or announce it during surveys.
What do I need to do differently on July 5th?
This is the most common question ASHE is hearing from members right now. The reality is that you will need to be prepared before July 5th on several items. The best way to approach this may be to start with Chapter 19 of the 2012 edition of the Life Safety Code for your health care occupancies and verify that you comply with the conditions for all existing facilities. In past instances where CMS adopts a new edition of the code, CMS has always identified through their interpretive guidance that all facilities need to comply with the chapters of the Life Safety Code on existing facilities regardless of when they were built.
I also highly recommend that you download (free to members) or buy a copy of the ASHE monograph that details differences between the 2000 edition and 2012 edition of the Life Safety Code. The monograph, Life Safety Code Comparison, sorts the differences by topic.
For the first time, CMS has also adopted NFPA 99 directly instead of by reference as in previous CoPs. It would be a good idea to take a look at NFPA 99 and review the applicability section of all chapters (except 7, 8, 12, and 13). The applicability chapter will include a list of any sections that you must follow for both new and existing facilities. Compliance will be required where noted in the applicability chapter.