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CMS Top 10 Life Safety Code Violations & the New Final Rule

August 10, 2016 David Spence Jump to Comments

Audits by Centers for Medicare & Medicaid Services accredited agencies can cause sleepless nights for those responsible for fire and life safety systems in healthcare occupancy types. Not only can the outcome lead to having to cut employees loose and steep fines, but because these audits results are reported publicly it can also have a negative impact from a public relations standpoint.

The fact is only 20% of facilities pass annually with zero discrepancies. To help facility management and maintenance better prepare for audits the CMS release a list of the top ten life safety discrepancies by the percentage of facilities cited. Keeping these in mind when preparing for an audit could help you become the one in five to pass your next audit rather than the exception.


  1. Sprinkler system maintenance - 21%
  2. Electrical wiring and equipment - 20%
  3. Hazardous areas - 15%
  4. Corridor doors - 14%
  5. Generator inspections and tests - 11%
  6. Access to exits - 11%
  7. Smoke barriers - 11%
  8. Fire drill frequency - 10%
  9. Fire alarm system testing and maintenance - 8%
  10. Sprinkler installation - 8%

On March 5th, 2016, the CMS published the final rule on fire safety requirements for a range of facilities, and in doing so adopted the National Fire Protection Association’s (NFPA) 2012 edition of the Life Safety Code (LSC) as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code. These changes include several updates and exceptions from the 2000 Life Safety Code (LSC) and the 2012 edition of the Health Care Facilities Code. The facilities impacted include:

  • Hospitals
  • Intermediate care facilities for individuals with intellectual disabilities (ICF-IID)
  • Ambulatory surgical centers (ASCs)
  • Religious non-medical healthcare institutions (RNHCI)
  • Programs for all inclusive care for the elderly (PACE)
  • Inpatient hospice facilities
  • Critical access hospitals (CAHs)
  • Long term care (LTC) facilities

Per the CMS, “Some of the main requirements laid out in this final rule include:

  • Health care facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date.
  • Health care facilities are required to have a fire watch or building evacuation if their sprinkler systems are out of service for more than ten hours.
  • The provisions offer LTC facilities greater flexibility in what they can place in corridors. Currently, they cannot include benches or other seating areas because of fire code requirements limiting potential barriers to firefighters. Moving forward, LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms (such as pictures and other items of home décor).
  • Fireplaces will be permitted in smoke compartments without a one hour fire wall rating, which makes a facility more home-like for residents.
  • Cooking facilities now may have an opening to the hallway corridor. This will permit residents of inpatient facilities such as nursing homes to make food for themselves or others if they choose to, and, if the patient does decide to make food, facility staff is able to provide supervision of the patient.
  • For ASCs, all doors to hazardous areas must be self-closing or must close automatically. Additionally, alcohol based hand rub dispensers now may be placed in corridors to allow for easier access.”
There are also new requirements expanding the use of sprinkler systems in high-rise facilities, but those facilities will have a period of 12 years to install them. For a full accounting of the final rule, you can refer to the Federal Register.

To learn more about how ScanSeries Healthcare and BuildingReports’ CMS accredited agency reporting formats can simplify inspection and compliance for The Joint Commission, DNV Healthcare, Inc., Healthcare Facilities Accreditation Program (HFAP) or The Center for Improvement in Healthcare Quality (CIHQ), click here.

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