Mutual Matters

Hospital Alert: CMS to Survey Compliance with New Fire Safety Standards

Posted by Georgette Samaritan, RN, BSN, CPHRM on Jun 28, 2016 2:00:00 PM

hospital.jpgThe Centers for Medicare & Medicaid Services (CMS) final rule amends the fire safety standards for Medicare and Medicaid participating hospitals, critical access hospitals (CAHs), long-term care facilities, intermediate care facilities for individuals with intellectual disabilities (ICF-IID), ambulatory surgery centers (ASCs), hospices which provide inpatient services, religious non-medical health care institutions (RNHCIs), and programs of all-inclusive care for the elderly (PACE) facilities.

The final rule, effective July 5, 2016, requires healthcare facilities to follow the 2012 editions of NFPA 101: Life Safety Code® and NFPA 99: Health Care Facilities Code.

Some of the requirements include:

  • Doors with roller latches will be limited only to “doors to corridors, and to rooms containing flammable or combustible materials.”
  • By 2028, buildings taller than 75 feet will have to install automatic sprinkler systems.
  • Facilities will be required to have a fire watch and evacuate if a fire sprinkler system is out of order for more than 10 hours.
  • For new construction only, window sills must not be higher than 36 inches above the floor.

The Joint Commission is revising its applicable standards to meet the new CMS CoPs, adopting the National Fire Protection Association’s 101 Life Safety code, effective July 5. CMS is giving the Joint Commission 60 days from June 8, 2016 to submit revised standards, surveyor tools, documents and training.

In addition to the Federal Register, cited below, The American Society for Healthcare Engineering (ASHE) cites a number of 2012 Life Safety Code® adoption resources, including Webinars, On Demand Records and other Education Programs on the ASHE website: ASHE also has a feature on its website, whereby hospital engineers may submit common questions concerning the new regulations. In addition, the ASHE Annual Conference in Denver July 10-13, 2016, will provide several important sessions on the new regulations.


Federal Register; Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities, Final Rule 05-04-2016;


MMPSI, June 28, 2016

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