What you need to know about the CMS adoption of the 2012 Life Safety Code

July 27, 2016

Published: May 17 2016

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:

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.

Joint Commission creates compliance checklist for new imaging room standards

July 26, 2016

The Joint Commission recently shared data from survey reports on the most common noncompliant areas related to new and revised diagnostic imaging room standards. Now the organization has released a compliance checklist so that hospitals can perform self-assessments and prepare for on-site surveys.

The free downloadable checklist provides:

  • Yes/No columns to check off compliance
  • Comment section to add site-specific notes for each requirement
  • Sign-offs for individuals to confirm compliance

CLICK HERE to read about and download the free compliance checklist.

Study: More than 90 percent of strokes are preventable

July 25, 2016

Jul 18, 2016 | Caitlin Wilson

Strokes are one of the leading causes of death globally, but it turns out a vast majority of them could be prevented, according to findings published July 15 in the British journal The Lancet .

According to the study authors, almost 91 percent of all strokes can be prevented through 10 healthy lifestyle changes and healthcare improvements.

This conclusion came from studying almost 27,000 participants from nearly every region of the world between 2007 and 2015. Among the more than 13,000 strokes observed, about 90.7 percent of them were caused by only 10 risk factors, including hypertension, lack of physical activity, poor diet, smoking, alcohol consumption, psychosocial factors and diabetes.

All of those risk factors can be controlled through better healthcare (blood pressure drugs, diabetes management) and changes in lifestyle (better diet, smoking cessation), meaning that the vast majority of all strokes can therefore be prevented.

Some of the risk factors that were found to be the cause of most strokes observed were lack of physical activity at 36 percent, poor diet at 23 percent and obesity at 19 percent.

What’s more, the results were consistent across geographical areas, ethnicities, ages and genders, said researchers, though the importance of some risk factors varied by region.

Based on this data, the study authors called for improved stroke-prevention programs. Better understanding and wider availability in healthcare could help prevent some of the leading causes of stroke, and public health initiatives could promote the lifestyle changes necessary to decrease stroke risk.

CLICK HERE to read the original; story in Cardiovascular Business

Top 55 hospitals patients would definitely recommend

July 22, 2016

 When patients fill out HCAHPS surveys about their experience receiving care in a hospital, one question might say more than any other about the overall feeling an organization left them with: Would they recommend that hospital to others?

The following 55 hospitals had 91 percent or more of their patients report yes, they would definitely recommend this hospital in their HCAHPS surveys. The national average is 71 percent.

HCAHPS data this list is based on is available through CMS’ Hospital Compare database, representing responses given between July 2014 and June 2015.

Note: This list excludes hospitals that had fewer than 100 patients complete HCAHPS surveys. Hospitals with the same percentage are listed according to provider number, rather than alphabetically.

Westlake Regional Hospital (Columbia, Ky.) — 98 percent

Patients’ Hospital of Redding (Calif.) — 97 percent

Southeastern Regional Medical Center (Newnan, Ga.) — 97 percent

Oklahoma Heart Hospital (Oklahoma City) — 97 percent

Unity Medical and Surgical Hospital (Mishawaka, Ind.) — 95 percent

Advanced Surgical Hospital (Washington, Pa.) — 95 percent

Orthopaedic Hospital of Wisconsin (Glendale) — 95 percent

Cancer Treatment Centers of America (Philadelphia) — 95 percent

Sutter Surgical Hospital — NorthValley (Yuba City, Calif.) — 94 percent

Physicians Medical Center (Houma, La.) — 94 percent

Surgical Institute of Reading (Wyomissing, Pa.) — 94 percent

Black Hills Surgical Hospital (Rapid City, S.D.) — 94 percent

CLICK HERE to see the rest of the list.

Documentation in paper records more accurate than in EHRs, study finds

July 21, 2016

When it comes to clinical documentation, physicians tended to chart more accurately on paper records than in the EHR in one study published in the Journal of the American Medical Informatics Association. However, EHR documentation tended to be more thorough.

Researchers retrospectively analyzed 500 progress notes from Beaumont Hospital – Royal Oak (Mich.), some completed on paper prior to the hospital’s transition to an EHR July 1, 2012, and the rest from the EHR.

They found EHRs had a 24.4 percent rate of inaccurate documentation, compared to 4.4 percent on paper charts. However, complete physical examination findings were omitted from 41.2 percent of paper notes, compared to being omitted from 17.6 percent of EHR notes.

“Further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation,” researchers concluded

Free Whitepaper – The State of the Medical Imaging Market

July 20, 2016

To improve patient care, hospitals must find a way to easily access medical images regardless of  their source. Download “The State of the Medical Imaging Market” to discover how to achieve this goal with an enterprise-wide, vendor neutral archive that leverages the cloud for quick wins and benefits over time.


CLICK HERE to download the free whitepaper


Top 10 costliest specialty drugs for insurers

July 19, 2016

 A recent study from the University of North Carolina at Chapel Hill revealed specialty drug costs for payers have tripled since 2003, when they represented 11 percent of payer drug spending.

Here are the top 10 costliest specialty drugs in 2014:

Name, use, average 30-day supply cost

1. Sovaldi, pill to treat hepatitis C, $28,083*

2. Stelara, injection to treat psoriasis, $11,131

3. Gleevec, pill to treat leukemia and other cancers, $10,893

4. Gilenya, pill to treat multiple sclerosis, $6,743

5. Copaxone, injection to treat multiple sclerosis, $6,623

6. Tecfidera, pill to treat multiple sclerosis, $6,407

7. Humira, injection to treat rheumatoid arthritis, $3,890

8. Enbrel, injection to treat rheumatoid arthritis, $3,674

9. Atripla, pill to treat HIV, $2,853

10. Abilify, pill to treat psychiatric disorders, $1,011

Researchers used the Truven Health MarketScan Commercial Database to analyze prescriptions purchased by commercially insured patients, and defined specialty drugs using CMS’s threshold, which designates a product costing $600 or more for a 30-day supply as a specialty drug. 

*Sovaldi is usually taken only for 12 weeks with at least one other medicine. Other listed drugs are typically taken for years until they become ineffective or the patient switches treatment.


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