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CMS Proposes Adoption of Updated Life Safety Code


Wednesday morning, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule regarding adopting the 2012 edition of the Life Safety Code (LSC). CMS states the updated code contains new provisions that are vital to the health and safety of all patients and staff.


Currently, CMS applies the fire safety standards set out in the 2000 edition of the LSC. CMS states the 2012 edition is better aligned with international building codes and will make compliance across codes simpler for Medicare and Medicaid-participating facilities.

The Health Care Facilities Code (HCFC) contains more detailed provisions specific to health care and ambulatory care facilities. It is a cross-referenced document in the LSC. The HCFC provides minimum requirements for the installation, inspection, testing, maintenance, performance and safe practices for health care facility materials, equipment and appliances.

The new edition of the LSC applies to hospitals, long-term care facilities (LTC), critical access hospitals (CAHs), ambulatory surgical centers (ASC), intermediate care facilities for individuals with intellectual disabilities (ICF-IIDs), hospice inpatient care facilities, programs for all- inclusive care for the elderly (PACE) and religious non-medical health care institutions (RNHCIs). 

Proposed Rule Highlights 

Key changes for hospitals, LTC facilities, CAHs, ASCs, hospice inpatient facilities and ICF-IIDs include:

  • Increased size of sleeping suites. Newly-constructed sleeping suites can be up to 7500 square feet. 
  • Use of sprinklers in high-rise buildings. All high-rise buildings over 75 feet tall must have automatic sprinklers installed throughout the building. Existing facilities have 12 years to install automatic sprinklers. 
  • Controlled access doors. Facilities may lock interior doors where patients' special needs require specialized protective measures. The ability to lock interior doors is subject to five requirements.
  • Sprinkler system requirements. If a sprinkler system is out of service for more than four hours, the building must be evacuated, or a person or persons must monitor the facility for a fire and notify appropriate individuals in an emergency. 

Key changes for ASCs: 

  • Interior nonbearing walls. Interior nonbearing walls must have a minimum 2 hour fire resistance rating if constructed of fire-retardant treated wood that is enclosed within noncombustible or limited combustible materials. Walls with fire-retardant treated wood cannot be used as shaft enclosures. 
  • Doors. All doors to hazardous areas must be self-closing or close automatically

Key changes for ICF-IIDs:

  • Sprinklers. New facilities must install sprinkler systems in all habitable areas, closets, roofed porches, balconies and decks. 
  • Attics. New and existing facilities must protect attics with an approved automatic sprinkler system if the attic is used for living purposes, storage or housing of fuel-fired equipment. If the attic is used for other purposes, or not used, then it must meet one of four requirements listed in the LSC. 
  • Means of escape. Facilities must ensure designated means of escape are continuously free of all obstructions or impediments.
  • Smoke alarms. Newly-constructed facilities must install approved smoke alarms in and around sleeping areas and on all levels within a residential unit. 
  • Access-controlled egress doors. New and existing facilities are permitted to have access-controlled egress doors that meet the requirements in the LSC. Doors may be equipped with electronic locks to prevent egress. 
  • Hazardous areas. Smoke partitions must separate hazardous areas from other parts of the building. This provision applies to existing facilities with impractical evacuation capabilities.
  • Emergency forces notification. Existing facilities with a new or replaced fire alarm system must notify emergency forces in accordance with the LSC. 


Essentially, this proposed rule will mean major changes to the fire safety requirements a health care facility must follow, if adopted. The comment period for the proposed rule closes on June 16, 2014 . If you are interested in this area and would like more information or the opportunity to comment on the proposed rule, Baker Donelson can assist you. Sheila Burke, chair of the Government Relations and Public Policy group, or any of our attorneys and policy advisors in our Health Law and Long Term Care groups are ready to help identify issues and answer questions.

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