Changes take effect July 5, 2016.

CMS has adopted the 2012 codes (NFPA 101®-2012 Life Safety Code® and most of NFPA 99-2012 Health Care Facilities Code.)  However, the full consideration of this change also requires taking into account the impact of changes in the referenced documents that will now be 10 to 15 years newer.  We recommend that health care organizations assess now the impacts of all changes on their processes.  There will need to be some updates to related plans, policies, procedures and forms to reflect those changed requirements.

The CMS press release, with a link to the final rule, was issued on May 3, 2016.  The final rule itself, entitled “Fire Safety Requirements for Certain Health Care Facilities (CMS-3277-P)” was published in the May 4, 2016 Federal Register.  The final rule should also be downloaded from the Federal Register as a certified PDF document.  The CMS Analysis of and Responses to Public Comments begins at Federal Register page 26882 within the downloadable certified PDF as Section III.

The accrediting organizations are expected to follow CMS’ adoption of the 2012 codes shortly.

ASHE has issued an advocacy alert along with some other very useful information for its membership.

NFPA has established a web page of NFPA resources related to the new CMS requirements.

CMS adopted, as part of the NFPA 101®-2012 Life Safety Code®, four Tentative Interim Amendments to NFPA 101®-2012 (TIA 12-1, TIA 12-2, TIA 12-3 and TIA 12-4) that were issued prior to April 16, 2014 when CMS published the proposed rule for public comment.  NFPA cautions that not all printed copies of NFPA 101®-2012 will include the changes resulting from those four TIAs.  The NFPA web page mentioned above also includes links to each of the four NFPA 101®-2012 TIAs that were adopted by CMS.

CMS also adopted, as part of the NFPA 99-2012 Health Care Facilities Code, five Tentative Interim Amendments to NFPA 99-2012 (TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6) that were issued prior to April 16, 2014 when CMS published the proposed rule for public comment.  NFPA cautions that not all printed copies of NFPA 99-2012 will include the changes resulting from those five TIAs.  The NFPA web page mentioned above also includes links to each of the five NFPA 99-2012 TIAs that were adopted by CMS.  We recommend that healthcare organizations consider acquiring the NFPA 99-2012 Handbook because of the drastic changes in the 2012 edition of NFPA 99.  CMS did not adopt chapters 7, 8, 12 and 13 of NFPA 99-2012 for the reasons outlined within the proposed rule.

Generally the final rule includes the requirements of the proposed rule with some modifications (clarifications.)  The CMS clarifications for hospitals can be found on Federal Register page 26890 within the downloadable certified PDF.  Those CMS clarifications include:

• “We are clarifying that the prohibition on roller latches applies only to doors to corridors and to rooms containing flammable or combustible materials.”
• “We are clarifying that all outpatient surgical departments must meet applicable provisions in Ambulatory Health Care occupancy chapter, regardless of the number of patients served.”
• “We are revising the requirements for the shutdown of a sprinkler system for an extended period of time.”
• “We are removing the requirement for installation of a dedicated air supply and exhaust system in windowless anesthetizing locations.”
• “We are revising the window sill requirement for new construction only to indicate that such sills must not be higher than 36 inches above the floor.”

What about the other NFPA standards?

SSR’s September 2015 Compliance News article “What about the other standards?” addressed another impact of this change.  A portion of that article is repeated below for reference.

Most hospitals are very familiar with the construction/renovation aspects of newer codes and standards (for example NFPA 70 National Electrical Code™, NFPA 90A governing air conditioning and ventilating system installation, and NFPA 13 governing sprinkler system installation, among many others.) These consensus-based national standards are often invoked by state and local building codes whenever renovation and new construction projects are undertaken.  Another example is when AHJs invoke a newer edition of the Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities. An ASHE FGI Guidelines reference page includes a link to an FGI Guidelines adoption status map.

Below are just some examples from the list of over 50 newer NFPA standards that can have requirements invoked for CMS CoP compliance now that CMS has adopted the 2012 Life Safety Code® and most of the 2012 Health Care Facilities Code.  These newer standards have changed, and those changes will definitely affect hospital facilities department inspection, testing and maintenance (ITM) processes.

Staff training is warranted where newer requirements will result in changes to existing processes.  Both ASHE and NFPA have been offering webinars and publications dealing with many of the changes. Many of the remaining 2016 conferences will also address some of the changes.

Questions related to this article may be directed to the author, David Stymiest, PE, CHFM, CHSP, FASHE, at DStymiest@ssr-inc.com.