REGULATORY REVIEW


CMS Adopts 2012 Life Safety Code What your facility needs to know to be compliant BY KARA NEWBURY


The Centers for Medi- care & Medicaid Services (CMS) recently


adopted.


provisions of the 2012 edi- tions of the Life Safety


Code (LSC) (NFPA 101) and the Health Care Facilities Code (NFPA 99) in order to “simplify and modernize the con- struction and renovation process for affected health care providers and sup- pliers, reduce compliance-related bur- dens, and allow for more resources to be used for patient care.”


Background


The LSC is a set of fire protection requirements published by the National Fire Protection Association (NFPA) and designed to provide a reasonable degree of safety from fire. Until July 5, 2016, CMS used the 2000 edition of the LSC to survey for health and safety compliance. Health care facilities, including ASCs, must comply with the newly adopted regulations by July 5, 2016, unless otherwise specified in the final rule. There are several areas in which the 2012 version will apply to new facilities only, so new facilities must have all pre-construction approv- als in place before July 5, 2016, or meet the 2012 requirements.


ASC-Specific Changes In the Final Rule, CMS identified the following changes as specifically impacting ASCs:


Self-Closing Doors


Sections 20.3.2.1 and 21.3.2.1 of the LSC require all doors to hazardous areas to be self-closing or close auto- matically. Hazardous area is defined as “an area of a structure or building that poses a degree of hazard greater than that normal to the general occu-


pancy of the building or structure,” but an asterisk by that definition references an appendix clarification. The appen- dix states: “A.8.7.1.1 Areas requiring special hazard protection include, but are not limited to, areas such as those used for storage of combustibles or flammables, areas housing heat-pro- ducing appliances, or areas used for maintenance purposes.” For both new and existing facili-


ties, any door required to be self- closing is permitted to be held open only by an automatic release device. The required manual fire alarm sys- tem and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Although most of the changes are


effective July 5, 2016, ASCs have until July 5, 2017, to comply with this requirement.


Alcohol-Based Hand Rubs The Final Rule outlined the changes in the 2012 LSC that allow for the use of alcohol-based hand rubs (ABHRs). The LSC articulates specific require- ments in terms of the size, storage and protection of the ABHR as well as the level of alcohol in the ABHR. In addi- tion, Section 20.3.2.6(11) and Section 21.3.2.6(11), for new and existing facil- ities, respectively, outline the require- ments for the operation of the dispenser, including: activation of the dispenser, amount of solution dispensed and test- ing in accordance with the manufactur- er’s care and use instructions each time a new refill is installed.


Fire Extinguishment Requirements In the proposed rule, CMS proposed to modify the fire extinguisher require-


ments, requiring the evacuation of the building or instituting a “fire watch” when a sprinkler system is out of ser- vice for more than four hours in a 24-hour period. After receiving feed- back from the industry, CMS withdrew this proposal and adopted the require- ment “specified by NFPA for an evacu- ation of a building or the instituting of an approved fire watch when a sprinkler system is out of service for more than 10 hours in a 24-hour period until the system has been returned to service.”


Other Significant Provisions The rule impacts ASCs in several other ways as well. Included below is infor- mation on what CMS proposed, ASCA’s comments on the proposal and the final determinations that CMS made.


Fire-Rated Separations Between Occupancy Types The proposed rule incorporated the 2012 requirements for fire-rated sep- arations between different occupancy types. ASCs fall under the Ambulatory Health Care occupancy type and, per those requirements, all adjacent occu- pancies need to be separated from the ASC by two-hour fire-rated construc- tion in buildings without automated sprinkler systems.


This separation


must be both horizontal and vertical and applied to new and existing facil- ities and buildings. ASCA requested that CMS exempt existing facilities from this requirement and that ASCs be held to the 2000 LSC, which only requires smoke barriers for horizon- tal occupancy separations. CMS in its final rule decided to keep the current requirements of the 2000 edition of the LSC as ASCA requested.


Fire Protection Requirements In the 2012 NFPA 101, the fire pro- tection requirements for penetrations changed from offering protection com- parable to that required for the surface penetrated to requiring that penetra-


ASC FOCUS AUGUST 2016 21


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