CMS Grants Multiple Categorical Waivers to Reduce Hardship

By Marty Piepoli, MSW, CHFM, HACP

On August 30, 2013, CMS released Survey and Certification Letter 13-58-LSC to address several provisions in the 2000 edition of the Life Safety Code (LSC)® that may result in unreasonable hardship for healthcare organizations, for which an adequate alternative level of protection may be achieved. If organizations choose to take advantage of one or more of these waivers, they must document their decision to utilize the waivers.

Actions taken to comply with the waivers should be documented in the Environment of Care Committee minutes and also the organization’s Basic Building Inventory of the Statement of Conditions. TJC Engineering has indicated that the Traditional Equivalency process will not be required. For surveys conducted by CMS, the organization must notify the survey team at the opening conference and that it has chosen and meets the applicable waiver provisions. The following items are addressed in the waiver:

  1. Medical Gas Master Alarms: Allows substitution of a centralized computer system for one Category 1 medical gas alarm.
  2. Openings in Exit Enclosures: Permits existing openings in exit enclosures to mechanical equipment spaces that are protected by fire-rated door assemblies; these mechanical equipment spaces must be used only for non-fuel-fired mechanical equipment, must contain no storage of combustible materials, and must be located in sprinklered buildings.
  3. Emergency Generators and Standby Power Systems: NFPA110, 1999, which is referenced in the current LSC, requires diesel-powered generators that do not meet the monthly testing requirements under section 6-4.2 to be run annually with various loads for a total of two (2) continuous hours. In order to reduce undue cost burden and negative environmental impacts, the waiver will permit a reduction in the annual load-bank test from two (2) continuous hours to one hour and 30 minutes (1-1/2 continuous hours) in compliance with section of the 2010 NFPA 110.
  4. Door-Locking Arrangements: The current LSC permits door locking arrangements where clinical needs of patients require specialized security measures for safety. These areas include; psychiatric units, dementia units, pediatrics, newborn nurseries, patients that pose a security risk in the ED, etc. The focus has always been on having processes in place for the rapid removal of patients in an emergency, by way of remote control locks or keys carried by staff. The waiver which references the 2012 edition of the LSC will allow door locking arrangements where clinical needs justify them, security risks or where patients require specialized protective measures for safety. This will also include permitting more than one delayed-egress lock in the egress path.
  5. Suites: The current LSC requires every habitable room to have an exit access door leading directly to an exit access corridor. The waiver will further accommodate the use of suites by allowing: (1) one of the required means of egress from sleeping and non-sleeping suites to be through another suite, provided adequate separation exists between suites; (2) one of the two required exit access doors from sleeping and non-sleeping suites to be into an exit stair, exit passageway, or exit door to the exterior, and (3) an increase in sleeping room suites size up to 10,000 ft.
  6. Extinguishing Requirements: The waiver will permit use of NFPA 25, 2011 to allow for the reduction in the testing frequencies for sprinkler system vane-type and pressure switch type water-flow alarm devices to semi-annual, and electric motor-driven pump assemblies to monthly. The organization must be in compliance with all other aspects of NFPA 25, 1999 for the waiver to be permitted.
  7. Clean Waste & Patient Record Recycling Containers: Allows an increase from the current 32 gallon container covered under LSC 2000, Sections 18/ to 96 gallons if the sole use of the container is for recycling of clean waste or for patient records awaiting destruction outside of a hazardous storage area.
  8. Clarification of Process for LSC Waivers permitted under S&C-12-21: The waiver released in March, 2012 addressed several aspects of the 2012 LSC for use by hospitals, critical access and long-term care. Specific to hospitals, the waiver allowed for emergency medical equipment such as crash carts and patient life equipment and transportation devices to be placed in the corridor without “in use” restrictions. The waiver also permitted fixed furniture in the corridor. For use of the items described above, facilities may now use the categorical waiver process defined under 13-58.

The release of this waiver demonstrates that CMS is moving forward with its review of the 2012 edition of the LSC. Hopefully this rule-making change will be completed within the next 6-12 months. Organizations should confer with their individual accrediting bodies with regard to how a specific survey process will be impacted. Be on the look-out for updates from The Joint Commission or any specific publication from your accreditor. Minimally, each organization should be completing a comparison of the 2000 and 2012 versions of the LSC to address the impact of each waiver area being permitted and to document acceptance or changes related to the waiver in Environment of Care Committee minutes and the organization’s Statement of Condition as applicable. Please see a comparison completed by ASHE for the recent waivers released by CMS impacting LSC.

Courtemanche & Associates will keep you informed as this process impacting the safety of organizations evolves over the coming months.

CMS S&C Letter 13-58-LSC released August 30, 2013
Chart Summarizes CMS-Approved Life Safety Code Waiver: Lynn Kenney, ASHE Senior Advocacy Analyst. ASHE Insider, September 10, 2013
The Life Safety Code is a registered trademark of the National Fire Protection Agency

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