Fall 2016 | cbservices.org

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New Life Safety Code Requirements for Licensed Skilled Nursing Facilities

Utilizing the Proper Editions of the NFPA Codes and Standards By Stan Szpytek, GB RCCS Associate Consultant

New Life Safety Code (LSC) requirements have been officially implemented for licensed skilled nursing facilities in the United States effective July 5, 2016.  As most providers of this level of healthcare know by now, the Centers for Medicaid and Medicare Services (CMS) will start to enforce the 2012 edition of the Life Safety Code (NFPA #101) instead of the previously enforced 2000 edition of the code. 

These requirements only apply to licensed skilled nursing homes but should be considered as a “Best Practice” for Risk Pooling Trust members that provide similar healthcare services without CMS oversight.

Further, while adoption of the 2012 edition LSC started on July 5, 2016, CMS has announced that enforcement of this edition of the code will not officially begin until November 1, 2016 so federal, state and county-contracted CMS life safety surveyors can be trained on the newer edition of the code. 

It should also be noted that while there is a 2015 edition of the Life Safety Code published by the National Fire Protection Association (NFPA) and in use by some jurisdictions, it must be reiterated that the 2012 edition of the code will be enforced in licensed skilled nursing facilities that receive CMS funding.

Skilled nursing facility providers should understand that other editions of select codes and standards published by the National Fire Protection Association (NFPA), as well as other agencies have also been adopted by reference (in full or in part) with the 2012 edition of the LSC and will be enforced.  Here is a listing of some of the other key NFPA codes and standards that will be enforced along with the applicable editions of the documents:

NFPA 99 (2012 ed.) - Healthcare Facilities Code (with some exclusions)

NFPA 13 (2010 ed.) - Standard for the Installation of Sprinkler Systems

NFPA 25 (2011 ed.) - Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems

NFPA 72 (2010 ed.) - National Fire Alarm and Signaling Code

NFPA 14 (2010 ed.) - Standard for the Installation of Standpipe and Hose Systems

NFPA 96 (2011 ed.) - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

NFPA 10 (2010 ed.) - Standard for Portable Fire Extinguishers

NFPA 80 (2010 ed.) - Standard for Fire Doors and Other Protective Openings

All of the NFPA referenced codes and standards, as well as other publications including ACI, ANSI, ACME, ASSE, ASTM, FMGR, NEMA, UL and U.S. Government publications are listed in Chapter 2 of the 2012 edition of the Life Safety Code.

What can be confusing is that there are more recent editions of all of these NFPA codes and standards already in publication.  If a licensed SNF provider were to reference and utilize a more recent edition of one of these documents, they would not be using the correct edition of the code or standard for the purposes of CMS compliance.  Each different edition of NFPA codes and standards has either minor or major changes that can impact interpretation, implementation and enforcement.

As a consultant conducting Mock Life Safety Surveys of nursing homes around the country, I often encounter the well-intentioned administrator or maintenance director who is excited to show me that they have the newest edition of a code or standard in their library to use for Life Safety Code compliance.  Of course, I have to inform them that they are using the wrong edition of the document.  While each edition may be fundamentally similar in general content, there always are changes from edition to edition that will have impact on implementation and enforcement practices.

One NFPA standard that has significantly changed its content and appearance is the Healthcare Facilities Code (NFPA 99, 2012 ed.).  http://catalog.nfpa.org/NFPA-99-Health-Care-Facilities-Code-Prior-Years-P4108.aspx?icid=B484.  This document has been completely re-written and changed its general format from being a standard to becoming a code.  The 2012 edition of the Healthcare Facilities Code requires healthcare facilities to  conduct a risk assessment of its critical systems to determine what sections of the code will apply based on the levels of identified risk.  Essentially, an assessment will be required to determine the impact that the loss of a particular utility or system will have on Life Safety conditions within the facility.  Based on this assessment and the specific risk category that is identified on a scale of 1 through 4, appropriate sections of this code will apply and be enforced.

Another significant change to the Life Safety Code is the addition of a new chapter that addresses building rehabilitation.  Chapter 43 entitled, “Building Rehabilitation” has been added to address work associated with the following:

1.            Repair
2.            Addition
3.            Modification
4.            Reconstruction
5.            Change of use or occupancy classification
6.            Addition

This new chapter of the LSC must be utilized when this type of work occurs in existing healthcare facilities as required by other sections of the code.

Now that the landscape of LSC utilization and enforcement has changed, it is essential for providers to become more familiar with new editions of the codes and standards along with several other changes.  SNF providers should work closely with their design, construction, sustainability and maintenance teams to ensure that they are referencing the appropriate editions of all applicable codes, standards and publications.  Failing to reference and utilize the proper editions of the NFPA codes and standards, as well as other referenced publications in the LSC can have adverse consequences.

To better understand some of the changes between the 2000 edition and the 2012 edition of the LSC, please review the comparison chart that was developed and being provided as a resource with the permission of the chart’s author, Brad Keyes of Keyes Life Safety Compliance.