CMS Announces Procedures for Implementation of Life Safety Code Provisions Under New Conditions for Coverage

Abstract

Two days after their February 9, 2009 effective date, the Centers for Medicare and Medicaid Services (CMS) announced procedures for the implementation of the Life Safety Code (LSC) component of the new Conditions for Coverage and provided details as to the expansion of the waiver-related and other exceptions to compliance with this requirement (Table I). Sprinkler and automatic fire alarm and notification equipment are required for “new facilities” but not for “existing facilities” To meet “existing facilities” exception, certificate of occupancy must have been received before 10/14/08 and facility must be located in a building built before 1/1/08 (all permits obtained before that date) “Major renovation” or relocation of an existing facility removes exception applicable to “existing facilities” … facility becomes a “new facility” to which the LSC provisions apply Facility certificate of occupancy date moved from 10/14/08 to 2/9/09 Building permitting date moved from 1/1/08 to 10/14/08 “Major renovation” is one that involves >50% or >4500 sf of the “smoke compartment of the facility” Cosmetic change (such as painting or floor replacement) is not a “major renovation” No state has yet been approved to use its fire and safety code State application and waiver process is outlined in 9/5/2008 CMS survey and certification letter CMS waiver permitted only if compliance would result in “unreasonable hardship for the facility” and failure to comply will not have any “adverse effect” on the health and safety of the facility's patients Waiver may be time limited Waiver is requested in response to notice of deficiency and is filed in lieu of Plan of Correction as to that item Waiver statement must describe “unreasonable hardship” and must also document lack of “adverse effect” on patients Application process is outlined in 11/21/2008 CMS survey and certification letter In its memorandum, CMS confirmed that the LSC provisions apply to all owned or leased dialysis facilities, including home training facilities, regardless of the number of patients served. However, CMS will not require separation by a fire wall of “shared use” portions of a dialysis facility (such as an exam room used by nephrologists within a dialysis facility) from the rest of the dialysis facility. As summarized in “CMS Issues Interpretive Guidance for Survey Process Under New Conditions for Coverage,” CMS had previously indicated that additional information as to the time-limited waivers contemplated by the Conditions for Coverage would be forthcoming.1